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AFFIDAVIT OF NOTICE OF REVOCATION OF AUTHORIZATION (R07) ELECTRONIC FUND TRANSFER

Requirement: Complete the form, print 2 copies (retain 1 for your records), notarize and mail to the address below.

STATE OF HAWAII
CITY & COUNTY OF HONOLULU

I, , depose and say that I have revoked the authorization of the Payee/Originator identified below to make Electronic Fund Transfers (EFT's) from my Hawaii State Federal Credit Union (hereafter referred to as HSFCU) account identified below.
Payee/Originator:
HSFCU Account No.:
Payment Date:
Payment Amount:

ACH Source No.: (credit union use) __________________
I acknowledge that it is my responsibility to notify the Payee/Originator of the revocation and to comply with the authorization agreement that I entered into with the Payee/Originator, and I warrant and represent to HSFCU that I have already done this.

I release, indemnify, and hold harmless HSFCU from any and all liability associated with the Notice of Revocation of Authorization. I agree to monitor my account and to advise HSFCU in the event of the item posting in such a time that will allow a legal return of the item. I understand that HSFCU is not required to make the return under any agreement, written or implied.

I understand that this stop payment will expire 6 months from today’s date: _______________________, 20_____


Phone Number

E-mail Address

____________________________
Member Signature

Subscribed and sworn to before me this ____ day of __________, 20___


____________________________
Notary Public, State of Hawaii


Name


My Commission Expires

Please complete, print, sign and mail to:
Hawaii State Federal Credit Union
Attn: Webmail
P.O. Box 3072
Honolulu, HI 96802-3072