Stop Payment (ACH)

Please complete the following to request a Stop Payment on an Electronic Payment:

Full Name *

Member Number *

Please provide your preferred contact information

Dollar Amount of Electronic Payment *

Issue Date *

Originating Company *

Reason for Stop (Choose One)

Revoking Authorization of Recurring Electronic Payments

Revoking a One-Time only Electronic Authorization

Please read the following before submitting:

I understand by submitting this electronic Stop Payment form I am agreeing to all the conditions as mentioned below.
I will notify the originating company of this stop payment.
I understand that the amount I list above must be correct for the stop payment to take effect.
I agree to indemnify and hold Success CU harmless from all liability, damage, and expense incurred as a result of refusing payment of said check.
I understand I must notify you in writing, if, and when the stop payment ceases to exist.
I understand that this stop payment order expires six months from the date hereof unless I renew it in writing.
I understand that Success CU will not be liable for paying an item on the day the stop payment is received.
I agree to allow Success CU to charge my account $20.00 for this stop payment request and acknowledge receipt of a copy of this order if I so request and accept and agree to the terms thereof.

I agree that I have read all information above. *

Yes, I agree.