P.O. Box 3205
Church Street Station
New York, NY 10007
(212) 693-4900

ACH Stop Payment Request / Cancellation

Please complete, sign and return this form to either request or cancel a stop payment of an electronic (ACH) payment transaction. If you were provided with a pre-addressed envelope with this form, please use it to expedite delivery. You can also fax the completed request form to (212) 416-7304.

If you requested a stop payment verbally, please be aware of the following: A stop payment request is effective for fourteen (14) calendar days only unless a written request, signed by the account owner and meeting MCU specifications, is received. If a written request, signed by the account owner and including all required information, is not received by MCU within 14 calendar days, your verbal stop payment request will cease to be binding and MCU may honor subsequent debits to your account.

Member Name



Account No

<table border="1"><tr><td>08/23/19</td></tr><tr><td>Date</td></tr></table>

Brooklyn NY 11207-1012



Address / City / State / Zip



Please place a stop payment on the following ACH Debit.

<table border="1"><tr><td>EXACT Name of Party Originating Payment(Select“All”to stop ACH payments from all parties)</td><td>Reference Number(Leave blank if unknown)</td><td>Next Scheduled Presentment Date</td><td>EXACT Amount(or ANY Amount)</td></tr><tr><td>Capital One
All</td><td></td><td></td><td>0.00
Any Amount</td></tr></table>

<table border="1"><tr><td>Service Charge: I agree to pay MCU a fee of $20.00 to be debited from my account for placing this stop payment.</td><td>02 FASTRACK CHECKI(Savings/Checking/MMA)</td></tr></table>

MCU's Agreement to Act: I understand that MCU’s sole responsibility pursuant to this stop payment request will be to attempt to act in accordance with this request within a reasonable period after it has been received and accepted. I understand and acknowledge that MCU will not be liable for its failure to stop an ACH debit unless my request was received at least three (3) business days prior to the scheduled presentment date and includes all required information.

**Recurring Payments:** I understand that this stop payment request authorizes MCU to stop all ACH payments matching the information indicated above until either the verbal request expires or the written, signed request is cancelled.

Cancellation: I understand that a written, signed stop payment request will remain in effect until MCU processes a written, signed request from me to cancel it, which may take up to 3 business days after receipt of my request.

<Cancellation Date (OPTIONAL)>: Please cancel the above-referenced stop payment as of ___.

Note: We recommend that you notify the originating party directly if you are revoking your authorization for the ACH payment(s) listed above.

Member Signature



08/23/19



Date

<table border="1"><tr><td>For MCU Use Only:</td><td>MCU Employee</td><td>Date</td></tr><tr><td>Received by:</td><td>DANY DOMINGUEZ</td><td>08/23/19</td></tr><tr><td>Reference No.</td><td></td><td></td></tr><tr><td>Incident No.</td><td></td><td></td></tr><tr><td>Entered By:</td><td></td><td></td></tr><tr><td>Verified By:</td><td></td><td></td></tr></table>



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