Substitute Check Recredit Claim

Form Instructions

Written Request for Refund

Today's date:
Member #:
Member's Name who either wrote or deposited the original check:
Address 1:
Address 2:
Home Phone:
Work Phone:

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Substitute Check Information

Check this box if the Substitute Check or a copy of the Substitute Check is being submitted with this form.

If the Substitute Check or a copy of the Substitute Check is not being submitted with this form, please provide the following information:

The check number:
The name of the person to whom the check was written:
The amount of the check: $
The date of the check:

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Amount of Loss

Estimate of the total amount of your loss (includes interest owed or fees paid): $

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Description of the Loss

Describe why you have suffered a loss:

	The Substitute check was improperly charged to the account
	The Substitute Check was charged from your account more than once

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Need for Original Check

Explain why the Substitute check you received is insufficient to confirm that you suffered a loss:

	Information contained on the Substitute Check is illegible (for example, the amount)
	Physical examination of the check is necessary (for example, to prove forgery) because: 400 characters maximum

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Signature

You declare under penalties of perjury that the above information is true and correct.

___________________________________________ Member Signature

Revocation of Claim

You hereby revoke this expedited recredit claim and release Star One Credit Union from any liability with regard to the same.

___________________________________________ Member Signature

_______________________ Date

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