A charge, as reflected, will be assessed to the account holder as payment for implementing this order. Fee Assessed $30.
By directing the Financial Institution to stop payment on the above transaction(s), the account holder agrees to hold the Financial Institution harmless against any and all loss, claims, damages, and costs, including court costs and attorney’s fees, that the Financial Institution may suffer or incur by reason of non-payment of the above transaction if presented prior to withdrawal of these instructions or expiration thereof. The account holder understands that the stop payment request must be received at least three (3) business days before a scheduled debit(s) or in time to give the Financial Institution reasonable time to act upon it. The account holder also understands that it is necessary to provide the correct information related to the transaction(s) and that failure to do so may result in the payment of the above items(s). The account holder agrees to hold harmless and indemnify the Financial Institution for all expenses, costs, and damages incurred by payment of the above item(s) if such payment is the result of failure of the account holder to meet the time requirements noted above, or if such payment is the result of failure of the account holder to furnish any item of information requested above completely, accurately and correctly.
I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the debit above was not originated with fraudulent intent by me or any person acting in concert with me. I have read this statement in its entirety and attest that the information provided on this statement is true and correct.