STOP PAYMENT REQUEST FORM
Last Revision: 11/30/2021

STOP PAYMENT REQUEST FORM

Form Instructions

Items 1 through 15 are to be completed by the Requester of the Stop Payment Request:

  1. Select the date this request form is being completed
  2. Select the appropriate check type from the drop-down list. Options include Accounts Payable or Payroll
  3. Enter the name of the individual preparing this form
  4. Enter the Payee Name as it appears on the check
  5. Select the appropriate ID type from the drop-down list. Options include PSU Employee #, SIMBA Supplier #, or Student Refund
  6. Enter the correspondinging ID number
  7. Enter the complete mailing address of the Payee including street address, city, state, and zip code
  8. Enter the Payee's telephone number, inclduing area code
  9. Enter the check #
  10. Enter the Account # as it appears on the face of the check
  11. Enter the Check Date
  12. Enter the Check Amount
  13. Is the check to be reissued? Check Yes or No
  14. Select the instructions for reissed check from the drop-down list. Options include Mail Check, Pick-Up Check, or Other. If other selected, complete next section
  15. If other is selected in reissue check instructions, provide complete details

Items 16 through 21 are to be completed by Accounting Operatons:

  1. Select the date stop payment placed
  2. Enter the name of the individual placing the stop payment
  3. Enter the bank confirmation number
  4. Enter the SIMBA Cancel Payment Document number
  5. Enter the SIMBA Reversal Document number
  6. Enter any notes as appropriate
Image of Stop Payment Request Exhibit