STOP PAYMENT REQUEST FORM

STOP PAYMENT REQUEST FORM
Today’s Date _________________________________ Time ___________________
Account Name ______________________________
a.m.
p.m.
Consumer
Account Type
Corporate
Contact Phone No. ___________________________________________
Payable to __________________________________ Transaction Amount $_________________________________________
Expected Clearing Date of Item(s) ________________ Reason for Stop Payment ______________________________________
Account Number ______________________ Check Serial No.(s) ___________________ Date Check(s) Written______________
Single ACH Payment (Consumer Account)
On the terms hereinafter set out, the undersigned account holder hereby instructs Kentucky Farmers Bank, hereinafter
called “Kentucky Farmers Bank”, to stop payment on the above transaction. The stop payment order shall remain in
effect
(1) until written notice is received from the account holder to revoke the stop payment order; or
(2) until payment of the entry has been stopped, whichever occurs first.
Recurring ACH Entries (Consumer Account): Verify Standard Entry Class Code (circle one) PPD TEL WEB IAT
On the terms hereinafter set out, the undersigned account holder hereby instructs Kentucky Farmers Bank, hereinafter
called “Kentucky Farmers Bank”, to stop payment on the above transaction(s).
The account holder authorized _____________________________________ to originate one or more ACH entries to
debit funds from the above account,
(1) But on ___________(date), revoked that authorization by notifying_________________________________
(company name) in the manner specified in authorization; or
(2) Will be notifying ________________________________________(company name) on __________(date) in the
manner specified in the authorization.
(Financial Institution check if applicable) If Kentucky Farmers Bank checks this box then the account holder agrees to
provide Kentucky Farmers Bank with written confirmation of the revocation with
__________________________________________ (company name) within 14 calendar days from today’s date. If
Kentucky Farmers Bank does not receive the required written confirmation, then it will honor subsequent debits to
the account.
One Ach Payment (Corporate Account)
On the terms hereinafter set out, the undersigned account holder hereby instructs Kentucky Farmers Bank, hereinafter
called “Kentucky Farmers Bank,” to stop payment on the above transaction. The stop payment order shall remain in
effect for six months.
Check
On the terms hereinafter set out, the undersigned account holder hereby instructs Kentucky Farmers Bank, hereinafter
called “Kentucky Farmers Bank,” to stop payment on the above transaction. The stop order shall remain in effect for six
months.
A charge, as reflected, will be assessed to the account holder as payment for implementing this order. Fee Assessed $_______25.00__________________
By directing Kentucky Farmers Bank to stop payment on the above transaction(s), the account holder agrees to hold Kentucky Farmers Bank harmless against any and
all loss, claims, damages, and costs, including court costs and attorney’s fees, that Kentucky Farmers Bank may suffer or incur by reason of nonpayment of the above
transaction if presented prior to withdrawal of these instructions or expiration thereof. The account holder understands that the stop payment must be received at least
three (3) business days before a scheduled debit(s) or in time to give Kentucky Farmers Bank reasonable time to act upon it. The account holder also understands that
it is necessary to provide the correct information related to the transaction(s) and that failure to do so may result in the payment of the above item(s). The account
holder agrees to hold harmless and indemnify Kentucky Farmers Bank for all expenses, costs, and damages incurred by payment of the above item(s) if such payment
is the result of failure of the account holder to meet the time requirements noted above, or if such payment is the result of failure of the account holder to furnish any
item of information requested above completely, accurately, and correctly.
I am an authorized signer, or otherwise have authority to act on the identified in this statement. I attest that the debit above was not originated with fraudulent intent
by me or an person acting in concert with me. I have read this statement in its entirety and attest that the information provided on this statement is true and correct.
Date_______________ Account Holder Signature______________________________________ Print Name___________________________
I (account holder) release Kentucky Farmers Bank from its obligation to stop payment on the above transaction(s).
Date_______________ Account Holder Signature______________________________________ Print Name___________________________
For Financial Institution Use Only
Verbal Stop Payment Request Accepted On _______________________________ By __________________________________________________________
Signed Stop Payment Request Accepted On _______________________________ By __________________________________________________________
Written Confirmation of Revocation Received On ___________________________By __________________________________________________________