ACH STOP PAYMENT FORM
Netspend Corporation
PO Box 2136
Austin, TX 78768-2136
www.netspend.com
Phone: 866-387-7363 Fax: 866-358-0526
Email: disputedocuments@netspend.com
Customer Name:
Merchant Name:
Date of Last ACH Debit:
Customer Phone Number:
Stop ALL FUTURE payments to this merchantStop only this ONE payment to this merchant
Please select only one:
If you wish to release the Stop-Payment Order described above, please sign below and return this form to Netspend Corporation
so we may remove the Stop-Payment Order from our records.
The Stop-Payment Order above hereof is released.
Customer Signature ____________________________________________ Date _______________________
Release should bear same authorized customer signature as original Stop Order.
Expected Amount of ACH Debit:
Customer Reference Number:
Date of Request:
You are requesting Netspend, on behalf of your issuing bank, to stop an Automatic Clearing House (ACH) debit as specified
above. A Stop Payment request on a preauthorized transfer must be received by Netspend at least three banking days before the
scheduled date of transfer. For non-recurring, single transaction ACH items, you must provide us the stop payment request with
sufficient time so that we may reasonably act on the request. We are not liable if we do not receive the order in sufficient time
before the transfer occurs.
You attest that all the information provided above is correct. If the item is presented differently than as described above, the item
may be paid with no liability to Netspend or your issuing bank.
Please e-mail the completed and signed form to disputedocuments@netspend.com, or print the completed and signed
form and fax to 866-358-0526, or mail to PO Box 2136 Austin, TX 78768. *E-mails containing sensitive and confidential information,
including information contained in the ACH Stop Payment Form, should be sent using a secure, encrypted e-mail. Unencrypted e-mails you send may not be
secure and may potentially be accessed and read by persons other than to who it is addressed.
Customer Signature____________________________________________________ Date_____________________________
Date of Expected ACH Debit
_______________________________________________________________________
Cancel Stop-Payment Order
