Mid American Credit Union STOP PAYMENT REQUEST

DATE OF REQUEST

TIME OF DAY REQUEST TAKEN BY UNT NUMBER
MEMBER'S NAME

CHECK NO. DATED AMOUNT
PAYABLE TO

REASON
INPUT ON COMPUTER BY

TIME INPUT STOP PAYMENT
CHARGE $
CIRCLE ONE:
        CASH               CHARGE

Please stop payment on the above-described item. In requesting the credit union to stop payment of this item, the undersigned member agrees to furnish the credit union with the exact amount, date, number, name of payee and such other information pertaining to said item as the credit union may request, and failure to furnish such information shall relieve the credit union of any liability for payment made contrary to this request. Undersigned member agrees to reimburse the credit union for all expenses and loss resulting from refusing payment pursuant to this order, or if by reason of such payment other checks by the undersigned member are returned unpaid because of insufficient funds. This stop payment order is subject to the provisions contained in the undersigned member's signature card. The fee to stop payment is $10.00.

The member understands that he/she may only stop payment on items signed by him or herself and not items signed by other joint tenants. The member agrees to hold credit union harmless from loss caused by the member's abuse of this stop payment privilege.

This request is effective from the date after its receipt by the credit union. A verbal request will be honored for 14 days. A signed request will be honored for 6 months. Unless the request is renewed in writing after the initial 6 month period, the credit union may pay the items without inquiry or notice to the member and any such payment shall be deemed to have been in good faith.


Authorization to Cancel Stop Payment


Signature________________________Date____________
___________________________________________
AUTHORIZED SIGNATURE

Mail completed form to:
Mid American Credit Union
8404 West Kellogg Drive
Wichita, Kansas 67209