ACH - Revoke/Stop Payment Request
KFCUR24257-11/19
1440 Rosecrans Avenue, Manhattan Beach, CA 90266
800.854.9846 | kinecta.org
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SECTION 1
Name Member Number
Daytime Phone Cell Phone
Payment Type
Pre-authorized Electronic Payment (ACH)
Check One
One-time Stop Payment Request
Permanent Revoke/Stop Payment Request
Date Payment Scheduled
SECTION 2
Company Name (Originating Company Name)
Company ID Number (Identification Number currently being used by the Originator)
Exact Dollar Amount (dollar and cents)
Reason For Stopping Payment
Fee Charged
SECTION 4
AUTHORIZATION TO RELEASE AN ACH STOP PAYMENT ORDER
I, the member or an account owner, hereby authorize Kinecta Federal Credit Union to release the stop payment listed above.
Account Owner’s Signature Date
SECTION 5
CREDIT UNION USE ONLY
Location Teller Number Date Request Received
SECTION 3
DISCLOSURE: A REVOCATION of authorization means that the written agreement with the originating company which was signed or similarly
authenticated by an employee, customer, or member to allow payments processed through the ACH (Automated Clearing House) network to be
deposited in or withdrawn from an account at a financial institution has been cancelled. This request must be received at least 3 business days
before the payment is scheduled to be made. (Failure to give us your request at least 3 business days prior to a transfer, we may attempt, at
our sole discretion, to stop the payment. We, Kinecta Federal Credit Union, assume no responsibility for our failure or refusal to do so, however,
even if we accept the request for processing.) The requested revocation/stop payment may be placed using the Company Identification Number
currently used by the Originator to debit or credit the account listed on this form. A fee will be imposed when the stop payment request is
processed; see the current Schedule of Fees and Charges for the current fee. Revoking and/or placing a stop payment order on an electronic
(ACH) item or draft will not cancel any authorization with the originator of the ACH transfer. You understand that you must contact the originator
to cancel the automatic payment. Kinecta Federal Credit Union requires the information on this form to be verified by you.
You or an account owner must immediately notify Kinecta Federal Credit Union if any information contained on this form is incorrect. If we,
Kinecta Federal Credit Union, are not notified of any misinformation, it will be assumed by Kinecta that the information listed on this form
is accurate and complete according to the information provided by you. This revocation/stop payment request is permanent until written
authorization is received from you, an account owner, releasing the stop payment request.
You agree to defend and hold Kinecta Federal Credit Union harmless for all loss, damages, expenses, and cost incurred by us arising
out of any third party claims with respect to Kinecta refusing payment pursuant to this revocation/stop payment order.
Account Owner’s Signature Date
Mail to: EPS Department CU/16 c/o Kinecta Federal Credit Union, 1440 Rosecrans Avenue, Manhattan Beach, CA 90266
This form may also be faxed to: EPS Department 310.727.8219
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