Ach Stop Payment Request - Lge Community Credit Union


ACH Stop Payment Request
Form may be returned by fax to 770-420-3850
Date of Request ______________________
Anticipated Posting Date ___________________
Stop Payment Terms: I understand a stop payment order must be received in time to allow LGEccu a reasonable opportunity to act
on it prior to receiving the debit entry, usually three business days. To be effective, the stop payment order must also sufficiently
identify the payment. LGEccu agrees to stop payment on the referenced item(s) whereas the account holder (member) agrees to the
following conditions: Stop payment requests can only be done by stopping a particular check number (for physical checks) or by
company ID number (for ACH withdrawals). In order for LGEccu to obtain a company ID number, that company must have withdrawn
from the member’s account in the past.
Account # ____________________ Member Name __________________________________________________________________
Merchant (Payee) Name _______________________________________________________________________________________
Check # (If check converted to ACH) ______________________________________________________________________________
Amount of debit to be stopped $ _________________________________________________________________________________
Reason for Stop Payment: ______________________________________________________________________________________
Please select one:
One time stop payment: The stop payment order will remain in effect until (1) one payment of the debit entry
has been stopped, or (2) until you provide written notice to release the stop payment order (whichever occurs
first). Notify the originator that a stop payment was placed on a single entry and direct them to continue the
recurring payments.
Permanent Stop Payment: The stop payment order will remain in effect until such payment has been stopped
by the company or until you provide written notice to release the stop payment order. I understand that LGEccu
may require confirmation that I have revoked authorization with the Originator, and if I do not provide it within 14
days, the stop payment order will cease to be binding and subsequent payments will be allowed to post.
I hereby request a Stop Payment order on the above debit. I realize there is a $30.00 service fee for this Stop Payment Request to be
debited from my account. If the item is presented by a different method than I have indicated, the item may still be paid with no liability
to LGEccu. If the order is accepted orally and notice is given that a written confirmation is required, the written confirmation must be
received within fourteen (14) days of the oral order. I understand that if I authorize another payment to this company for any amount, I
must advise LGEccu in writing in order to prevent the return of the newly authorized entry. LGEccu is not responsible for posting or
return errors caused by insufficient or inaccurate information. In requesting the credit union to stop payment of this item, you agree to
hold the credit union harmless for all expenses and costs incurred for non-payment of this item.
LGEccu Rep (Initials & Tlr#) ________________Branch #______________ Date received_______________
For ACH Staff use only:
Company Name: ____________________ Company ID:____________________ Date:_____________
Revised 02/12


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