Stop Payment Request Form

Form for customers or authorized account holders to request a stop payment on a check, capturing check details, payee information, amount, reason for the stop, and formal authorization including stop duration and fee acknowledgment.

Account Holder Information

• Account Holder Full Name
• Account Number
  Enter the full account number associated with the check. This information is handled securely.
• Bank Routing Number
• Daytime Contact Phone Number
  We may call to verify your identity before processing this request.
• Email Address
  A confirmation of your stop payment order will be sent to this address.

Check Details

• Check Number
  Found in the bottom-left corner of the check.
• Check Amount (USD)
  Enter the exact dollar amount written on the check. If unknown, enter your best estimate.
• Is the amount above exact or an estimate?
• Date Check Was Written
  Enter the date printed on the face of the check.
• Payee Name (Pay to the Order of)
  Enter the full name of the individual or business the check was made out to.
• Memo / Reference (if any)
  Optional: Enter any memo line text written on the check to help identify it.

Reason for Stop Payment

• Primary Reason for Stop Payment
• Additional Details
  Provide any additional context that will help us process this request, including relevant dates, communications, or circumstances.
• Have you filed a police or fraud report?
  Required if reason is stolen check or suspected fraud.
• Police / Fraud Report Number
• Supporting Documents (optional)
  Upload any relevant documents such as a copy of the check, invoice, or correspondence with the payee.

Stop Payment Duration

• Stop Payment Duration
• Requested Stop Payment Start Date
  Typically today's date. The stop will be placed as soon as your request is verified and approved.
• Send renewal reminder before stop payment expires?

Fee Acknowledgment and Authorization

• I acknowledge that a stop payment fee will be debited from my account in accordance with the current fee schedule.
• I understand that if the check has already been paid or is in process, the stop payment order may not be effective, and the financial institution is not liable for payments made prior to the stop being placed.
• I certify that the information provided in this request is true, accurate, and complete to the best of my knowledge, and that I am an authorized signer on the referenced account.
• Authorized Signer Full Name (Print)
  Must match the name on the account.
• Authorized Signer Signature
  Your electronic signature constitutes a legally binding authorization for this stop payment request.
• Date of Authorization