Request For Stop Payment Of Personal Check
Please complete the form below:
*Indicates a required field.
MEMBER INFORMATION:
Member Account Number
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First Name
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Last Name
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Social Security Number
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Phone Number
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Address
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Address Line 2
City
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State
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Zip Code
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Email Address
Please provide your email if you would like a confirmation of form retrieval.
CHECK INFORMATION:
Please enter the last 10 digits from the bottom of your checks (Checking Account Identifier)
226077516 1317
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Last 10 digits
Check Number
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Check Date
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Amount
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Payable To The Order Of
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Purpose For Which Check Was Drawn
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Reason For Stop Payment
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$15 Fee Stop Payment of Personal Check
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Yes, I accept the $15 stop payment fee that will be deducted from my credit union account.
I/WE,
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(Enter First & Last Name), the undersigned, do depose and say that I am the lawful owner of the above Share Draft Account. I, therefore, request Financial Assurance Federal Credit Union to stop payment on the said instrument.I agree to hold Financial Assurance Federal Credit Union harmless of and from any loss, damanges, claim and expense, which may be sustained of incurred by Financial Assurance Federal Credit Union in respect to the herein above described original check. This agreement shall be binding upon my heirs, executors, administrators, and assigns.
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Yes, I agree to and have read the above paragraph stating the terms and conditions of the Stop Payment Request of Personal Check.
ELECTRONIC FORM SUBMISSION AGREEMENT
:
By submitting this form I am verifying the following:
1. The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the transaction requested above.
2. I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union.
3. I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval.
4. Entering my first and last name in the Electronic Signature field stands as the equivalent of a handwritten signature. Therefore, by entering fraudulent or false information, you are commiting forgeryy and are subject to the equivalent applicable laws and penal action.
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Yes, I agree to the terms and conditions of submitting this form Electronically as outlined in the guidelines above.
Electronic Signature (please print your first and last name)
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Date
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