of these instructions or expiration thereof. This form acknowledges the account holder’s request to stop payment on pre-authorized electronic funds transfers as indicated above. The member further represents that the debit transaction describe above was not originated with fraudulent intent by me or any person acting
ACH Stop Payment Request Payment Information: Member's Name: Account #: Originating Company Name: Transaction Amount: $ ___________________ OR Any Amount Check Serial #: (only for check-related debit entries) For pre-authorized entries, three business days advance notice prior to the expected transfer date of the debit entry is required to implement the stop payment request. If the stop payment order is received within three business days of the expected transfer date, ACCU will attempt to satisfy the request on the member, but will not be held liable if sufficient time was not provided for pre-authorized transfer that occurs within the three-business day period. The account holder also understands that it is necessary to provide the correct information related to the transaction(s) sufficient to enable the identification of the account and transaction(s) in question. ___________________________ (Member initial here) For all non-recurring, single transaction ACH payments, the stop payment request must be provided in a timeframe that allows reasonable opportunity for us to honor the request prior to finalizing the ACH entry. Please indicate your specific choice for stopping payment from the Originating Company named above checking the appropriate box: I wish to stop all future payments from this Originator indefinitely I wish to stop the next payment only (Future entries from this Originator are to be paid, unless I provide ACCU with additional stop payment order) I wish to stop a series of payments Identify the payment dates, or months, of the specific payments from the Originator you wished stopped: ________________________________________________________________________________________________________________________________ A fee of $ 30.00 will be assessed to the account holder as payment for implementing this order. Signature and Certification By directing ACCU to stop payment on the above transaction(s), the account holder agrees to hold ACCU harmless against any and all loss, claims, damages, and costs, including court costs and attorney's fees, that ACCU may suffer or incur by reason of non-payment of the above transaction if presented prior to withdrawal of these instructions or expiration thereof. This form acknowledges the account holder's request to stop payment on pre-authorized electronic funds transfers as indicated above. The member further represents that the debit transaction(s) describe above was not originated with fraudulent intent by me or any person acting in concert with me, and the signature below is my own proper signature. Name: Date: ______/______/_______ Signature: For Credit Union Use Only: Instruction Received By: America's Christian Credit Union 2100 E. Route 66, Glendora, CA 91740 800.343.6328 · www.AmericasChristianCU.com Time: Date: ______/______/_______ REV. 02/2021Adobe PDF Library 21.1.170