Your account will be charged a stop payment fee of $20.00.

Primary Member's Name:
Primary Account Number:
Daytime Telephone Number:
Date of Check:	//
Check Number:
Check Amount:	$
Check Payable To:

We have received your request that we stop payment on the check described above, unless we have already paid, certified or accepted it. Your request will cease to be effective six months from the date shown above. The Bank will not be liable for payment of the check contrary to this request unless payment is caused by the Bank's negligence and causes actual loss to you. The Bank's liability shall not, in any event, exceed the amount of the check. You must reimburse the Bank for any loss it sustains in honoring this request.