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Stop Payment Request Form

  • The account holder agrees to provide The First National Bank with written confirmation of the revocation within 14 calendar days from today's date. If The First National Bank does not receive the required written confirmation, then it will honor subsequent debits to the account.

    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 item(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 further state that the debit transaction(s) was not originated with fraudulent intent by me or any person acting in concert with me, and that the signature below is my own proper signature. I certify under penalty of perjury that the foregoing is true and correct.