NOTICE TO BANK TO STOP PAYMENT ON CHECK

Date:

To:

Bank Officer:

You are hereby directed to place a stop payment order and refuse payment upon presentment of the following check:

Name of Payee: _____________________________

Date of Check: _____________________________

Amount: _____________________________

Check Number: _____________________________

This stop order shall remain in effect until further written notice.

Name of Account: _________________________________

Signature of Account Holder:_________________________

Account Number: __________________________________

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