At your request, we have stopped payment on the check described below. Our records do not disclose that this order has been confirmed. If you wish it to remain in effect, please sign and return this copy to the Stop Payment Department. According to Delaware law, Stop Payment Orders not confirmed in writing within 14 days are not binding upon the Bank.

WE CANNOT ACCEPT RESPONSIBILITY FOR STOPPING PAYMENT ON THIS CHECK UNLESS WE HAVE BEEN GIVEN THE EXACT AMOUNT AND DATE.

Account Number:
Amount:

Check Date:
Check Number:

Date Received:
Time Received:

Payee:
Reason:

Replacement Number Issued:

Maker:
Address:

CONTACT MEANS: Phoned In     Phone Number:

Taken by:

In requesting you to stop payment of this or any other item, the undersigned agrees to hold you harmless for all damages, expenses and costs incurred by you on account of refusing payment of said item, and further agrees not to hold you liable, if by reason of this Stop Payment Order other items drawn by the undersigned are returned insufficient, or if the above described check is paid during transmission of this order to all our branches and tellers.

No stop payment request, renewal or revocation, except at Bank’s election, shall be valid if oral or unless served at the Bank. This request is effective for six months from the date hereof but written renewals may be made from time to time.

This shall be legally binding upon the undersigned and upon the executors, administrators, successors, or assigns of the undersigned.

Witness the hand and seal of the undersigned this:

Signature: ________________________________________