SAO Payroll Stop Payment/ACH Reversal Form
200 Piedmont Avenue, Suite 1604 West Tower, Atlanta, GA 30334 Phone (404) 463-1993, Fax (404) 463-5089
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Requestors Name:
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Requestors Phone Number:
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Requestors Email Address:
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Company Name:
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Company Number:
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Please select from the following Payroll Stop Payment/ACH Reversal options:
Please place a stop payment on the check described below.
Please contact the bank for an ACH Reversal on a payment described below.
Other
If you selected other above please give detailed information:
Advice/Check Number:
Issue Date/Effective Date:
Amount:
Employee ID:
Payee Name:
Reason:
ABA Number:
Account Number:
State Accounting Office Use Only
Date Paid
Reissue Date
Date Processed
Processed By SAO:
SAO Form: 100-B
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Indicates Response Required