STOP BANK DRAFT AUTHORIZATION
Effective ____________________ or with the next available deduction date, please cancel my bank
(Date)
draft of $________________.
(Amount of Deduction)
Draft Date:

1st

15th
Members Name _______________________________________ Phone_____________________
(Please Print)
Address: ________________________________________________________________________
(State)
(Zip)
(City)
Name of bank _____________________
Do you have more than one draft?
Yes No
Branch:


Griffith
Southlake
Membership Type
 Family
 Youth
 Hammond
 Whiting
 Adult
 College
If yes; name of member _________________________
Reason:
 Financial Reason (please ask about our financial assistance program)
 Moving
 Not Using
 Transferring to different facility (facility name) ___________________________________________
 Other (please specify) _______________________________________________________________
Member Signature: __________________________________________ Date _________________
Staff Initials: _____________
Office Use Only:
Cancelled on __________________ Cancelled by _____________________________________
 Griffith 
 Southlake 
Hammond
Whiting
Receipt of Stop Bank Draft
(To be completed by YMCA Staff)
Your membership bank draft will be cancelled starting the month of _________________.
(Month, Year)
___________________________________________
(Member Name)
_________________________
________
(Date Stop BD form was received)
(Staff Initials)
Please do not dispose of this receipt. If a problem arises with your membership
cancellation, this form will be required.
*All drafts cancellations must be submitted by (1st) first of the month for the 15th draft or the (15th)
fifteen of the month for the 1st draft in order to stop the next month’s payment.
Crossroads YMCA Inc.
201 N. Griffith, Griffith, IN 46319