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 & Signature Name & Signature Name & Signature Name & 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 UAE - 00012 - 042016 -V1