STOP PAYMENT FORM 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

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