Substitute Check Warranty Or Indemnity Claim Form printable pdf download

SUBSTITUTE CHECK

WARRANTY OR

INDEMNITY CLAIM

PLACE YOUR BANK’S NAME AND ADDRESS HERE

FORM

The undersigned (referred to as “I”, “me”, or “my”) hereby certifies as follows:

(1) I am a consumer who received a substitute check: (Expedited Recredit Procedures may

apply)

In paper form

Electronically (image)

(2)

I am a commercial/business client (Expedited Recredit procedures do not apply)

(3) I have received a statement or other notification from XYZ Bank indicating that: Check #

was charged to my account #

on (date)

in the amount of $

. The payee is

(4) This check is: (choose one)

A check I wrote

A returned deposited item

(5) I believe that I have a Warranty 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

Other (please explain)

(6) I believe I have an Indemnity Claim because I received a substitute check instead of my

original check. The following amount(s) are included in this loss amount:

a. Amount of Check: $

b. Amount of any fees assessed (i.e., overdraft charges, other returned check fees)

Lost interest

d. Other Fees $

Please explain.

(7) 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.)

Other- Please Explain

(8) 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 under the penalties of perjury that the contents of the foregoing

document are true and correct.

Date

Signature

Notarization here if needed

Substitute Check Warranty Or Indemnity Claim Form

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