Last
Name
|
_________________________________
|
|
| First
Name |
_________________________________
|
MI
|
________
|
| Street
Address |
_________________________________ |
State
|
________ |
| City
|
_________________________________ |
Zip |
_________________________________ |
| Work
Phone |
_________________________________ |
E-mail |
_________________________________
|
| Home
Phone |
_________________________________ |
|
|
| Account
# |
_________________________________ |
|
|
| Check
# to Stop |
_________________________________ |
Amount |
_________________________________ |
| Payable
To |
_________________________________ |
Date
Written |
_________________________________ |
| Disclosure:
All items must be accurate or our computer systems
will not properly stop payment. This stop payment
is good for fourteen days.
You need to print, sign and return this form to
create a stop payment that is valid for 180 days
(in person or by mail) |
_______________________________
Signature
|
________________
Date |
You
Must Print, Sign, and Return to Credit Union
FAX NUMBER: 770-565-3821
|
