REQUEST BANK TO PLACE STOP-PAYMENT ON CHECK

[DATE, ex. Wednesday, June 11, 1998]

[NAME, COMPANY AND ADDRESS, ex.

John Smith

XYZ Bank

1234 First Street

Suite 567

Anycity, Anystate 85245]

Dear [NAME, ex. John Smith],

I would like to request that a "stop-payment" be placed on the following check{s}:

CHECK # AMOUNT RECIPIENT DATE ACCOUNT #

[LIST CHECK NUMBER(S), AMOUNT(S), RECIPIENT(S), DATE(S) AND ACCOUNT NUMBER(S), ex.

12423 $1,203.23 ABC Co. 5/3/98 2132342-23423]

I hereby authorize the service charge to be deducted from my [savings / checking] account, #[CHECKING ACCOUNT NUMBER].

Sincerely,

[YOUR NAME, ex. Jill Jones]