Fillable Stop Payment Form - First State Bank Of Bedias printable pdf download

Stop Payment Form

Check, ACH/Electronic Check, Draft, Reoccurring Debit Card ACH

*Important* - In order to be effective, stop payment orders must be received in time to give us a reasonable opportunity to act on

it, and it should precisely identify the number, date, the amount of the item, and who it is payable to. We cannot accept liability for

failure to honor the stop payment if the check is cashed today by First State Bank of Bedias teller, has already been paid, or if any

information you have provided us is incorrect. We strongly suggest you open a new checking account if the stop payment is fraud

related.

Date of Request: ______________________________

Account Name: _____________________________________________ Account #: ______________________________

Payee/Originator: ___________________________________________________________________________________

Check # (If applicable): ______________________ Item Date: ____________________ Amount: ____________________

Reason for Stop Payment: ____________________________________________________________________________



Will Check be Reissued?

Yes

If yes, NEW check #: _______________



Stop Payment Fee:

Waived

Applied ($20.00)

Type of Transaction (Check one):



ACH/Electronic Check

Check/Share Draft/Paper Draft

Reoccurring Debit Card ACH



I would like the above payment stopped one time.

The ACH stop payment will remain in effect (1) for six months from the date of the stop payment order, (2) until one

payment of the debit entry has been stopped, or (3) until the Receiver withdraws the stop payment order, whichever

occurs earliest.



I would like to stop payment on the above mentioned transaction and all subsequent payments matching this

criteria.

I understand that this stop payment order applies only to the specific criteria listed above and is effective for a period of six

months. I understand to prevent from posting to my account after the expiration of this stop payment order I must (1)

revoke the authorization with this company in the manner specified in the authorization or (2) renew this stop payment

order.

The ACH stop payment will remain in effect (1) for six months from the date of the stop payment order, or (2) until the

Receive withdraws the stop payment order, whichever occurs earliest.

Stop Payment Terms and Conditions

I (the owner of the account number listing above) hereby instruct (financial institution) to stop payment on the above transaction(s).

It is my understanding that this stop payment order will expire no later than six months from the date of the stop payment order. I

understand that I may renew this request when the six-month period ends by completing a new Stop Payment Request Order. I

understand that placing a stop payment order on a recurring ACH transaction will not cancel my authorization with the merchant.

It is understood that by placing this Stop Payment Request on the transaction(s) listed above that the account holder agrees to hold

the financial institution harmless against any and all loss, claims, damages, and costs, including court costs and attorney’s fees, that

the financial institution may suffer or incur by reason of non-payment of the above transaction if presented prior to withdrawal of

these instructions or expiration thereof. I understand that placing a stop payment on a reoccurring debit card transaction may not

be honored IF the preauthorized debit authorization has preceded stop payment form or occurs on the date of this Stop Payment

Form.

Stop Payment Form - First State Bank Of Bedias

Related Articles

Related forms

Related Categories