ACH Payment Reversal Request

Customer Information

Company Name

Requester Name

Online Banking ID

Requester Email

Request Type

Transaction Reversal Request

Batch/File Reversal Request

ACH CO ID

Enter ten digit alpha numerical ID

ACH CO Name

Enter up to sixteen characters .

Destination Bank ABA

Enter nine digit Destination Bank ABA number.

Destination Account #

Enter up to seventeen digits.

Payee Name

Enter up to seventeen characters.

Transaction Amount $

Please enter an amount between ".01" and "9999999999.99". Only numbers with no commas. Two decimal points required.

Effective Date

Creation Date

ACH CO ID

Enter ten digit alpha numerical ID

ACH CO Name

Enter up to sixteen characters.

Batch Name

Enter up to ten characters.

Total Debits (Item Count)

Enter up to six digits.

Total Credits (Item Count)

Enter up to six digits.

Effective Date

Batch/File Amount $

Please enter an amount between ".01" and "9999999999.99". Only numbers with no commas. Two decimal points required.

File creation Date

Reason for Reversal