This is a 2 page form.
Please complete, print, sign, and mail this form to:
Star One Credit Union
P.O. Box 3643
Sunnyvale, CA 94088-3646

SUBSTITUTE CHECK EXPEDITED RECREDIT CLAIM
Written Request for Refund

Making an Expedited Recredit Claim. If you have received a Substitute Check and demonstrate that the original check is necessary to show that you have suffered a loss, you can use this form to make a claim for a refund. If you use this procedure, you may receive up to $2,500 of your refund (plus dividends if your account earns dividends) within 10 business days after we received your claim and the remainder of your refund (plus dividends if your account earns dividends) not later that 45 calendar days that the Substitute Check was correctly posted to you account.

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

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

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

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:
       

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



For Star One Use Only

Received by ____________________________ Date Claim Received (Postmark if received by mail) _______________
Notice of Valid Claim Provisional Credit Denial Reversal Sent on (date) _______________________
Date of Statement or Date Substitute Check Made Available: __________________________ Additional Information: