Substitute Check Recredit Claim

Form Instructions

Please complete, print, sign, and mail this form to:

Star One Credit Union
P.O. Box 3643
Sunnyvale CA 94088-3643

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.

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

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

Star One Credit Union use only

Received by (Operator ID and Initials)

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

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