Fillable Printable Sample Stop Payment Indemnity Agreement
Fillable Printable Sample Stop Payment Indemnity Agreement
Sample Stop Payment Indemnity Agreement
INDEMNITY AGREEMENT
Request for Stop Payment order on check issued by AS U
And
Request for replacement check
1. I certify that on ___________, 20____, ASU issued a check, number _____________, in the amount of
$____________ payable to ____________________________________________ (“the check”).
2. To the best of my knowledge, the check described above has been
lost stolen damaged destroyed (please check one)
I certify that I did not endorse the chec k and that I did not deliver it to any ot her payee for endorsement. I understand
that ASU will not accept a request for stop payment and replacement of a check for any check that has been
endorsed “in blank” (e.g., signature only with no restriction such as FOR DEPOSIT ONLY or PAY ONLY TO)
because such a check is considered a bearer instrument. I understand that if the check has been stolen, I must file a
police report that contains my signature and I must present a complete copy of that report to ASU. If the chec k has
been torn, mangled, or otherwis e d amaged, the or i ginal check must a ccompany this indemnity agreeme nt.
3. I am requesting that ASU place a stop payment order on the check described above and issue me a replacement
check. I
AGREE TO INDEMNIFY AND HOLD ASU, ITS SUCCESSORS OR ASSIGNEES, HARMLESS FROM ALL CLAIMS,
DEMANDS
, LOSSES, DAMAGES, LIABILITIES, OR JUDGMENTS THAT MAY ARISE FROM OR RELATE TO THE CHECK
AND THIS REQUEST TO STOP PAYMENT
. FURTHER, I WILL FULLY REIMBURSE ASU FOR ANY EXPENSES IT MAY
INCUR IN ORDE RING A STOP PAYMENT OF THE CHECK OR IN ISSUING A DUPL ICATE WHILE THE O RIGIN AL IS ST ILL
OUTSTANDING
, INCL UDI NG ANY ATTORNEY’S FEES.
o I authorize Student Accounts to issue a stop payment on the check listed above and I understand that
there is a $20.00 fee for reissuing stude nt account refunds.
4. If ASU is unable to stop payment on the check and is obligated (as determined solely by ASU in the exercise of
reasonable discretion) to pay a holder who presents the check to ASU or its bank for payment, I agree to promptly
pa y A SU wi thi n fi ve (5 ) b usin ess d ays o f no tice (ver bal or wr itte n) t he f ull a mo unt the che ck t oget her wit h all c ost s
and expense s that ASU may incur rela ting to the check and the o rder to stop payment. If I fail to promptly pay ASU
wit hin five busines s days of n otice, ASU may:
o Decline to permit me to register for future classes at ASU, place a hold on any release of my transcripts,
and hold on any diplomas that I might earn;
o File reports concerning the check and t his Agreement with la w enforcement agencies, repo rt to credit rating
services, credit collection agencies and attorneys concerning this indemnity agreement, the requests made
her ein and the facts upo n wh i ch this r eq uest is made; and/or
o Refer of this matter to the appropriate ASU office(s) for disciplinary action on behalf of ASU.
5. If I find the check, I will mark the face of the check “VOID” and then promptly return the check to ASU for
cancellation and destruction.
6. I understand that ASU is not required to accept this request for stop payment and issuance of a replacement
check. ASU may, in its sole discretion, decline to stop payment on the check and it may decline to issue a
replacement check.
__________________________________________ _________________________________________
Signature Date
__________________________________________ _________________________________________
Printed Name ASU ID Number
* Please verify current address is updated on My ASU for time ly delivery
