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Christian Community Credit Union
ELECTRONIC (ACH) STOP or PAYMENT REVOKED
Claims for refunds of previously posted ACH transactions must be filed within 60 days of the mailing date for the statement which lists the disputed transaction.

Instructions:
Complete, print and mail this form to:
Christian Community Credit Union
101 S. Barranca Ave.
PO Box 3012
Covina, CA 91722-9012


Section A
General Information - Complete this section for ALL requests

Member's Name:

Member's Acct #:

Member's Daytime phone # and extension:

Name of the company that displays on the ACH item:

Stop transactions for :
Any and all amounts from this company
Only transactions that are for $

For all stop payments requests : A $15.00 stop payment fee will be charged to your account.


Section B
Complete this section to stop ALL future ACH transactions defined in Section A

I have never authorized this company to originate ACH withdrawals from my Christian Community Credit Union account.
I authorized the company to originate one or more ACH entries, but I revoked that authorization on
(date)

I authorized the company to originate one or more ACH entries, but (complete one of the two lines below):
The amount withdrawn exceeds the amount I authorized.
The amount I authorized is $

The withdrawal was posted to my account on a date earlier that the date authorized.
I authorized the withdrawal to be posted no earlier than (date)


Section C -
Complete this section to request a refund for an ACH withdrawal previously posted
(Also complete section B to ensure these transactions are not posted again in the future)

An ACH withdrawal that posted to my account on (date) in the amount of
$ was not authorized by me and should be refunded to me.
I have checked one of the boxes below to indicate the reason:
I was not informed of (or did not authorize or initiate) the transaction.
The signatures on the original item are not authentic or authorized.
The orignal check or Point of Purchase transaction was dated more than 180 days from the date the entry was posted to my account.
The item to which the represented check entry relates was for an amount of $2,500 or more.
Amount of transaction $
The item to which the represented check entry relates has been altered.
The item to which the represented check entry relates has already been presented three times.
The item to which the check conversion entry relates has not been signed.
The item to which the represented check entry relates has been previously presented in its physical form.


Section D
Complete this section for a one time stop payment of an ACH item

Stop the payment of the ACH item (described in Section A) for the month of only.
A written stop payment on a transfer is binding upon an institution for only one month unless renewed in writing. An oral stop payment order is effective for 14 days unless confirmed in writing within 14 days of the oral request.


Section E -
Complete this section for all requests

I depose and say under penalty of perjury that the information above is correct and accurate, and that any disputed transactions were 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.
Signed: _________________________________________________ Date:


Section F -
To be complete by Christian Community Credit Union Employee
Employee Initials _______________ Date: _____________

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