Kindly stop payment on the following described check or ACH electronic transaction and honor duplicate thereof

Duplicate/Replacement Issued (if applicable)

In making this request the undersigned agrees to abide by the rules and Regulations outlined in the Uniform Commercial Code of this State. The Stop Payment will automatically expire in six months from date unless renewed in writing.

Service charge for this request: $25.00

VERBAL STOP PAYMENT REQUESTS BY PHONE OR OTHERWISE ARE VALID FOR A PERIOD OF FOURTEEN DAYS ONLY

**For all ACH Stop Payment orders, the bank will require a written Affidavit in addition to this Stop Payment Request Form. Contact the bank for details.

By submitting this application, I/we authorize a consumer credit report and verify the statements in this application. Furthermore, I/we agree to be bound by the terms and conditions of the debit card, and the electronic funds transfer disclosure, copies of which will be mailed to the applicant if a card is granted. Receipt of terms and conditions, and disclosure, and acceptance of such terms will be conclusively presumed by use of the card. If this is a joint application, the undersigned shall be jointly and severally liable for any and all debit card transactions. Both parties must sign if a joint account is desired.