SKU STOP PAYMENT & INDEMNITY AGREEMENT FOR LOST ITEM FORM
01/09
STOP PAYMENT & INDEMNITY AGREEMENT FOR LOST ITEM
You may complete this form online and print to sign and fax or mail as indicated above.
Description of Item:
Amount: Check Number: Date Purchased:
Payable to the Order of:
To: KeyPoint Credit Union,
I am the purchaser of the Item described above and certify that:
(1) The above information is correct;
(2) The above item has been lost, stolen or destroyed and
(3) The payee whose name appears on the item has not endorsed it.
In consideration of your issuing a refund, I agree:
(1) To hold you and your agents harmless from all damages, expenses or liabilities arising from this stop
payment;
(2) That you or your agents will not be liable if the item is paid by mistake or I give you incorrect information,
provided you follow your usual procedures for stop payment;
(3) That if the original instrument is found, I will promptly deliver it to you to cancel and destroy.
I agree to wait five (5) days from the date of this instrument before the funds will be reimbursed.
I understand and agree that you or your agents may be compelled to pay the original item after the stop
payment is properly made. This could happen if the item is presented with proper endorsements. Under
these circumstances I agree to reimburse you for the amount of the item.
The circumstances in which the item was lost, stolen, or destroyed are as follows:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
I declare under penalty of perjury that the foregoing is true and correct. Executed this ________________________ day of
_________________ , 20___ in the City of _______________________________and State of ________________________
MEMBER’S NAME (print or type):
MEMBER’S SIGNATURE: DATE:
STREET ADDRESS: CITY, STATE, ZIP CODE:
FOR OFFICE USE ONLY
ACCEPTED BY: BRANCH/DEPARTMENT: DATE:
APPROVED BY: ACCOUNT NUMBER TO CREDIT: DATE:
RELEASE OF STOP PAYMENT
CANCEL THIS ORDER ON (DATE): TIME: PURCHASE SIGNATURE: AUTHORIZED OFFICER SIGNATURE:
2805 Bowers Avenue
Santa Clara, CA 95051
Fax: (408)731-4068; Attn: Stop Payments
Reason for Stop Payment:
Did the Payee Sign the Item?
Official Check
Lost
Yes
Money Order
Stolen
No
Destroyed
