Ach Debit Activity Stop Payment Form
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1ACH DEBIT ACTIVITY STOP PAYMENT FORM
(to be used to stop a transaction before the ACH transaction posts to the account)
FORM MUST BE COMPLETED PROPERLY BY THE MEMBER AND SIGNED
BEFORE THE RETURN CAN BE PROCESSED
Date of Request __________________
Daytime Phone _________________________
Account Number ___________
Members Name _______________________________________
Exact Amount of Transaction $ ________________
This form acknowledges members’ request to stop payment on the preauthorized electronic funds transfer
shown below. If an item is presented and does not exactly match the information you provide on this form
or is presented in a different method than ACH debit it may be paid or returned according to bank
policies and procedures. The financial institution will not be held liability for costs and expenses arising
from the refusal to pay an item as to which the member has given a stop payment order.
A stop payment order will remain in effect until the member withdraws the stop
payment order in writing or by checking the option below.
Originating Company Name _______________________________________________
Date of Next Scheduled Payment ____________________________
o I am requesting to stop this debit for one-time only.
I understand there is a $_______ fee for each ACH stop payment and my account will be
debited accordingly.
_________________________________________________________
Members Signature
OFFICE USE ONLY
Return Code-R08 Stop Payment on Specific Debit Only
Instructions Received by Teller # _______________
Date ______________________
Time _____________
Stop Payment Processed by Teller # _______________
Item Returned Date __________________________________
(remove stop payment from the system after item has been returned if the option box is checked)
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