Date:

The Manager, United Bank Ltd.

Branch:

Emirate: , UAE Title:

Cheque(s) serial #

Issue Date:

Reason for Stop Payment:

Amount:

Lost

Pay Order # to

Kindly Cancel the enclosed: FDD#

Stop Payment of Cheque / Pay Order

Thank you.

For Bank Use Only

Charges Recovered:

NA

Police Report

Original Instrument

Account Holder Signature/Company Stamp

Account Holder Name Joint Account Holder Name

Joint Account Holder Signature/Company Stamp

d d / m m / y y y y

d d / m m / y y y y

Waived

Stop Payment Marked

PO / FDD cancelled

Acct Credited Cash Paid

Yes

In Person by Customer Through Mail/Messenger Through Fax

Reset

Pay Order# Original enclosed: Yes No

The amount (less bank charges) may be:

App Received By Sign Verified By Input By Supervised by:Name & SignatureName & SignatureName & SignatureName & Signature

Other

Beneficiary:

Issue Date:

Reason for Stop Payment:

Amount:

Lost

d d / m m / y y y y

Other

Beneficiary:

Credited to my/our above account Paid to me/us in Cash.

My / Our Account Number

UA

E - 0

0012

- 04

2016

-V1