[NAME, COMPANY AND ADDRESS, ex.
John Smith
XYZ Bank
1234 First Street
Suite 567
Anycity, Anystate  85245] 

Dear [NAME, ex. John Smith],

I would like to request that a "stop-payment" be placed on the following check{s}: 

CHECK #       AMOUNT        RECIPIENT               DATE            ACCOUNT #

[LIST CHECK NUMBER(S), AMOUNT(S), RECIPIENT(S), DATE(S) AND ACCOUNT NUMBER(S), ex.

12423           $1,203.23      ABC Co.                  5/3/98          2132342-23423]

I hereby authorize the service charge to be deducted from my [savings / checking] account, #[CHECKING ACCOUNT NUMBER].

Sincerely,

[YOUR NAME, ex. Jill Jones]