Fillable Ach Stop Payment Request - Usc Credit Union printable pdf download

ACH Stop Payment Request

Account Holder Name:

____________________________________________________

Account Number:

____________________________________________________

Originating Company Name:

____________________________________________________

Transaction Amount:

$ ________________

 Any amount

Check Serial Number:

_________________________

(only for check-related debit entries)

For pre-authorized entries, I (the undersigned) understand, three business days advance notice prior to the expected

transfer date of the debit entry is required to implement the stop payment request. If the stop payment order is

received within three business days of the expected transfer date, you will attempt to satisfy my request, but will not be

held liable if sufficient time was not provided for a pre-authorized transfer that occurs within the three business day

period. I also understand that it is necessary to provide the correct information related to the transaction(s) sufficient to

enable the identification of the account and transaction(s) in question.

______

(Account Holder initial here.)

For all non-recurring, single transaction ACH payments, the stop payment request must be provided in a timeframe that

allows reasonable opportunity for you to honor the request prior to finalizing the ACH entry.

Please indicate your specific choice for stopping payment from the Originating Company named above by

checking the appropriate box:

 I wish to stop all future payments from this Originator indefinitely.

 I wish to stop the next payment only.

(Future entries from this Originator are to be paid, unless I provide you with an

additional stop payment order.)

(

 I wish to stop a series of payments from (date) ____________ to (date) ____________.

Identify the payment dates, or

months, of the specific payments from the Originator you wished stopped above.)

A fee will be assessed to the account holder as payment for implementing this order:

Fee Assessed:

$__________

I agree to indemnify you against all liability, loss, costs, damages, attorneys’ fees, and other expenses, including, but

not limited to, any amount you are obliged to pay on the item, which you may sustain or incur as a consequence of

honoring this “ACH Stop Payment Request.”

This form acknowledges the account holder’s request to stop payment on pre-authorized electronic funds transfers as

indicated above. The account holder further represents that the debit transaction(s) described above was not

originated with fraudulent intent by me or any person acting in concert with me, and that the sig nature below is my own

proper signature.

________________________________________________________

____________________________

Signature

Date

For financial institution use only:

Instructions Received by: ___________________________________________________________

Date: _____________________ Time: _____________________

Ach Stop Payment Request - Usc Credit Union

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