ACH Stop Payment Request
Account Holder Name:
Originating Company Name:
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:
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
For financial institution use only:
Instructions Received by: ___________________________________________________________
Date: _____________________ Time: _____________________