ACH 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 $
debited accordingly.

fee for each ACH stop payment and my account will be

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)