Ach Stop Payment Form

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ACH STOP PAYMENT FORM
PLEASE COMPLETE THIS FORM TO PLACE AN ACH STOP PAYMENT ON THE
PREVIOUSLY AUTHORIZED ELECTRONIC FUNDS TRANSFER SHOWN BELOW.
COMPLETING THIS FORM WILL NOT RE-CREDIT FUNDS TO YOUR ACCOUNT BUT
WILL CAUSE A STOP PAYMENT TO BE PLACED ON A FUTURE DEBIT FROM THIS
COMPANY. MGEFCU MUST RECEIVE THIS SIGNED, COMPLETED FORM AND $20.00
FEE FOR THIS STOP PAYMENT TO BE PLACED. THERE IS NOT A FEE TO STOP AN
EXISTING STOP PAYMENT ORDER.
NEW STOP PAYMENT ORDER
CANCEL EXISTING STOP PAYMENT ORDER
MEMBER NAME
________________________________________
PHONE NUMBER
________________________________________
ACCOUNT NUMBER W/SUFFIX ________________________________________
COMPANY NAME
________________________________________
EXACT DOLLAR AMOUNT OF DEBIT
FOR TEMPORARY STOP PAYMENT ____________________________________
SELECT ONLY ONE OF THE FOLLOWING:
PLACE A PERMANENT STOP PAYMENT ON ANY FUTURE ACH AMOUNTS FROM
THIS COMPANY NAME. PHONE-CODE WORD CAN BE USED FOR A PERMANENT.
PLACE A TEMPORARY STOP PAYMENT ON THE ACH DEBIT AMOUNT FROM
THIS COMPANY NAME. MAXIMUM PERIOD OF 6 MONTHS FOR A TEMPORARY
STOP PAYMENT. MEMBER MUST SIGN FOR A TEMPORARY STOP PAYMENT.
START DATE__________________
END DATE_____________________
STOP PAYMENT FEE: $20.00
CHARGE MY ACCOUNT #______________________ FOR THIS STOP PAYMENT FEE.
I UNDERSTAND THAT IT IS NECESSARY TO PROVIDE THE CORRECT INFORMATION
RELATED TO THE TRANSACTION AND THAT FAILURE TO DO SO MAY RESULT IN
THE PAYMENT OF THE ABOVE ITEM. I UNDERSTAND THAT THIS STOP PAYMENT
DOES NOT CANCEL OR CHANGE THE CONTRACT I HAVE WITH THE ORIGINATING
COMPANY.
TO CANCEL
THAT
CONTRACT
AND
TERMINATE
MY PRE-
AUTHORIZATION DEBIT, I MUST FOLLOW THE SPECIFICATIONS OUTLINED IN THE
CONTRACT I COMPLETED WITH THIS COMPANY. BY DIRECTING MGEFCU TO STOP
PAYMENT ON THIS ITEM, I AGREE TO HOLD MGEFCU HARMLESS AGAINST ANY
AND ALL LOSS, CLAIMS, DAMAGES AND COSTS, INCLUDING COURT COSTS AND
ATTORNEY’S FEES THAT ARE INCURRED AS A RESULT OF MGEFCU HAVING ACTED
ON THIS STOP PAYMENT REQUEST.
MEMBER’S SIGNATURE____________________________________DATE________________
FOR CREDIT UNION USE ONLY
RECEIVED BY TELLER & FEE PAID___________ DATE RECEIVED____________________
TELLER WHO PLACED OR CANCELLED STP___________________ DATE______________

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