Stop Payment Request Form

Fields marked with an asterisk (*) are required.

• Campus *
  IUPUI IUPUC IUFW
• University ID number *
  Must be 10 digits. Currently entered: 0 digits.
• Name *

  First Last
• Address *

  Street address Address line 2 City State/Province/Region Postal/Zip code United States United Kingdom Canada Australia Netherlands France Germany ------- Afghanistan Albania Algeria Andorra Antigua and Barbuda Argentina Armenia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland Gabon Gambia Georgia Ghana Gibraltar Greece Grenada Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Country
• Phone *

  - Area Code - Prefix Line Number
• Email *
• Amount of Check *

  $ . Dollars Cents
• Reason *
  Lost Never Received Damaged Fraud

• Important Processing Information

  There is a fee for stop payment requests. The fee will be waived when the payee signs up for direct deposit.
  Stop payment processing may require up to five business days.
  If both the original and replacement refund checks are negotiated resulting in a loss to the university, the customer is responsible to reimburse the university from non-university funds.
  If there is a balance due on the student's bursar account, the refund will apply to the charges on the account and any excess funds will be refunded.
  It is the payee's responsibility to maintain valid direct deposit and mailing address information.
  Verify that you have granted Title IV Authorization for the appropriate campus (Indianapolis, Columbus, or Fort Wayne) at http://go.iu.edu/6hW.
  
  Please type your signature below to verify that you have read and understand the instructions included with this form. If the refund is the result of financial aid, I certify that I am still eligible to receive these funds and have granted Title IV authorization.

• *
  Maximum of 40 characters allowed. Currently entered: 0 characters.