Fillable STOP PAYMENT FORM please type or print in (Port of Richmond)

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STOP PAYMENT FORM please type or print in (Port of Richmond)

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Rev. 7/09
Name
Address
City
State
Zip Code
Phone Number
Check Expected Pay Date
Request for Revocation One Time Stop Payment
Payable to Retiree Beneficiary
Other (Power of Attorney)
Reason for Stop Payment Request Lost/Stolen Never Received
Closed Bank Account Other
Bank Name (if applicable) Payment Amount
Have you attached a new Direct Deposit Form? (ACH Users Only) Yes No
Stop Payment Terms & Conditions:
Signature Date
Check Number Check Status
Check Amount Date Stop Payment Processed
Replacement Check Number Replacement Check Issue Date
Official
On the terms hereinafter set out, the undersigned retiree/beneficiary hereby instructs the City of Richmond, Virginia:
Richmond Retirement S
y
stem
,
hereinafter called "the Retirement S
y
stem
,
" to sto
p
p
a
y
ment of the above transaction.
STOP PAYMENT FORM
For Richmond Retirement System Office Use Only
Social Security Number
ACH Stop Payment Type
This Stop Paymen
t
orde
r
shall remain in effect as requested
by
you
r
signature fo
r
p
aymen
t
indicated. B
y
directing the
Retirement System to stop payment on the above transaction, the retiree/beneficiary agrees to hold the Retirement
System harmless against any and all loss, claims, damage and costs, including court costs and attorney's fees that the
retiree/beneficiary/or Retirement System may suffer or incur by reason of not paying the above transaction if presented
rior to withdrawal of these instructions or renewal thereof.
The retiree/beneficiary understands tha
t
the Stop Paymen
t
For
m
mus
t
b
e received in time to give the Retiremen
t
Syste
m
reasonable time to act upon it. For checks, at least 10 days after the payment date. For ACH deposits, at least 72
business hours advanced prior notice prior to the expected date of transfer.
For ACH stop payments a new Direct Deposit Form must accompany your request for the Richmond Retirement System
to complete the stop payment transaction.
please type or print in ink
Transaction Type ACH/Electronic
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
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STOP PAYMENT FORM please type or print in (Port of Richmond)

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Completed 4 August 2020

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