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Stop Payment Request

A $30.00 fee will be charged for each Stop Payment placed.  Stop Payment orders are effective for 6 months after date accepted and will automatically expire after that period unless renewed in writing.  You agree to indemnify and hold the Bank harmless from all costs, including attorney's fees (to the extent permitted by law), damages or claims related to the claims of any payee, endorsee or joint owner, or in failing to stop payment of an item as a result of incorrect or incomplete information provided by you.  The Bank shall not be liable if, as a result of payment of the item subject to this order, other items drawn by you are returned due to insufficient funds.  You will notify the Bank promptly of the issuance of a check or item which is a duplicate of the check or item subject to this order, or upon the return of the original check.   Stop payments, when received,  will be processed during regular bank business hours.

Information about you and your account...
*Account #: *Social Security #:
*First Name:


*Last Name:     
*Address Line 1:  
  Address Line 2:  


*Home Phone:

Work Phone:

Information about the check...
 Check Number End Check #:
 Date (mm/dd/yyyy): Amount:
 Payable to:

 * REQUIRED entries.