Date:_______________________

Time:______________________ Day Phone:____________________________

Please stop payment on the following check(s):

Amount $: _____________________ Date Issued: _____________________________

Payee:________________________________________________________________

I accept full responsibility and hereby agree to indemnify, defend and hold harmless Clara Barton Federal Credit Union (CBFCU) for all liability, costs and expenses, including attorneys fees and court costs arising from the Drawee’s refusal to pay on item as to which the member has given a stop payment order. The Drawee agrees to exercise ordinary care in endeavoring to comply with a stop payment order, but if through inadvertence, oversight, accident or otherwise, the Drawee pays the item contrary to a stop payment order, the member and the Drawee agree that the Drawee shall be immediately entitled to charge the member’s account for the amount thus paid, and such charge shall stand regardless of whether the member is entitled to recover from the Drawee on account thereof, and the member’s sole remedy shall be to prove and recover only such actual money damages as may be occasioned to the member of only such item. I understand that my account will be debited $20.00 for the stop payment fee.

THIS STOP PAYMENT SHALL BE EFFECTIVE FOR SIX MONTHS FROM DATE OF ORDER HEREON (Unless renewed in writing). THEREAFTER CHECK PAYABLE ON DEMAND.

________________________________
Member’s Signature

Member notified of Service Charge amount ______

Verify that check has not cleared ______

Verify stop payment has not been placed ______

REV 4/99