Templates › Forms › SEO page

Run: Stop Payment Request Form

Stop Payment Request Form for collecting the check details, reason, and authorization needed to place a stop on a payment. Use it to reduce back-and-forth an...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Account Holder Information

Account Holder Full Name (required)

Account Number (required)

Enter the full account number associated with the check. This information is handled securely.

Bank Routing Number (required)

Daytime Contact Phone Number (required)

We may call to verify your identity before processing this request.

Email Address (required)

A confirmation of your stop payment order will be sent to this address.

Check Details

Check Number (required)

Found in the bottom-left corner of the check.

Check Amount (USD) (required)

Enter the exact dollar amount written on the check. If unknown, enter your best estimate.

Is the amount above exact or an estimate? (required)

Date Check Was Written (required)

Enter the date printed on the face of the check.

Payee Name (Pay to the Order of) (required)

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 (required)

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 (required)

Requested Stop Payment Start Date (required)

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. (required)

Yes No N/A

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. (required)

Yes No N/A

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. (required)

Yes No N/A

Authorized Signer Full Name (Print) (required)

Must match the name on the account.

Authorized Signer Signature (required)

Your electronic signature constitutes a legally binding authorization for this stop payment request.

Date of Authorization (required)

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free