Substitute Check Claim Form printable pdf download

SUBSTITUTE CHECK

CLAIM FORM

I, Client Name hereby certify:

(1) I am a consumer who received a substitute check:

In paper form

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(2)

I am a commercial/business client who received a substitute check

In paper form

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(3) This check is: (choose one)

A check I wrote

A returned deposited item

(4) The original check or a sufficient copy of the original check is necessary in order to

determine the validity of the check because: (check all that apply)

The information on the check is illegible

I believe the bank charged my account incorrectly

I do not recognize the payee

The check may be a forgery

(Note: this reason only applies if the original or a better copy of the substitute check is needed to

make the determination that the item is forged. If you know the item is a forgery, you must

complete a Forgery Affidavit instead of this form.)

Please enter any additional information concerning your request here:

(5) I believe that I have a claim because:(Check all that apply)

This check does not meet the requirements for a legal substitute check.

This check has been charged to/against my account more than once

Lost interest and/or fee refund requested (BANK will calculate)

Please enter any additional information concerning your claim here:

(6) The information needed to identify the substitute check is:

a. Check #

b. Account #

c. Date check was written

(or date returned, if known

)

d. Amount of check$

e. Payee

(7) Account has been opened less than 30 days:

Yes

Note: Recredited amounts may not be available immediately if you are a new client (account less than 30

days old) or if your account has been repeatedly overdrawn.

By my signature below, I affirm that the contents of the foregoing document are true and correct

to the best of my knowledge.

Date

Signature

Substitute Check Claim Form