TO DISCONTINUE THE PAYROLL DEDUCTION

I wish to discontinue the payroll authorization above, effective pay period

ending (date) _____________ .
(signature) am writing to request that you stop (insert company`s name) from making future
automatic withdrawals from my checking account. These charges are unauthorized. I canceled
my contract in writing with (insert company`s name) on (list your date of cancellation). The
Federal Reserve`s rules governing pre-authorized transfers (part of Regulation E) states the
following: "Once a financial institution has been notified that the customer`s authorization is no
longer valid, it must block all future payments for the particular debit transmitted by the
designated payee-originator." I would appreciate your immediate compliance with this federal
law. Please contact me if you have any further questions.
Read more: Letter for stoppage of premium insurance deductions? - How to write a letter for
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DATE: ____________________ SAP #:_______________ NAME:

________________________________________________________ (Last) (First) (MI)
SOCIAL SECURITY #:________________ My policy is with:
_______________________________________________ (Company Name) I have a current
payroll deduction in the amount of: __________ I hereby request that you stop further payroll
deductions for this Tax Sheltered Annuity (TSA). Please take the Final deduction from
my_______________________ paycheck. (Last month you want deduction taken from) I
understand that it is my responsibility to notify my agent/company.
_________________________________________ (Employee Signature) Return completed
form via Courier Rt. E or US Mail (PCSB PO Box 391 Bartow, FL 33831) To the attention of:
Risk Management STOP TSA PAYROLL DEDUCTION REQUEST FORM