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Statement Content
WRITTEN STATEMENT OF UNAUTHORIZED REMOTELY CREATED CHECK
Member Name (First, Last): <Customer Name>
Address: <Street Address>
<City, State, Zip Code>
Telephone Number: <Phone Number>
I am the owner of the account # at <Institution Name>. A remotely created check no. dated as of <Check Date>, made payable to in the amount of <$XX.XX> (“Remotely Created Check”), was
drawn on my account.
...
I acknowledge that, to the extent my account is credited for the amount of the Remotely Created Check, <Institution Name> will have the right to recover all amounts so paid from the person who created the Remotely Created Check, and to bring a criminal and/or civil action against such person, if it so elects.
I further acknowledge that as part of its investigation, <Institution Name> may need to disclose the contents of this Written Statement to third parties, and I hereby consent to such disclosure. I also acknowledge that to complete its investigation, <Institution Name> may require further information concerning the matters set forth herein, which I agree to provide. I agree to cooperate in any internal or other investigation and/or legal action taken with regard to this matter. I further agree to testify, declare, depose, or certify to the truth of any or all of the foregoing before any competent tribunal, officer, or person, in any case now pending or that may be instituted in connection with this matter.
...
I hereby declare under penalty of perjury that the foregoing is true and correct.
___________________________________________________________________ ___________________________________________________________
Signature Date
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WRITTEN STATEMENT OF UNAUTHORIZED REMOTELY CREATED CHECK Member Name (First, Last): Steve Rogers Address: 123 Main Street Evanston , IL 12345 Telephone Number: (111) 222 - 1234 I am the owner of the account # 1234567890 at ABC Bank. A remotely created check no. 0011 dated as of |
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07/01/2024, made payable to in the amount of $500.00 (“Remotely Created Check”), was |
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drawn on my account. I hereby certify that the issuance of the Remotely Created Check was not authorized by me with regard to either the amount stated on the Remotely Created Check, the payee stated on the Remotely Created Check, or both. I further certify that the Remotely Created Check was not created at my request, approval or direction, nor did I otherwise indicate my consent to the creation of the Remotely Created Check. I also certify that the Remotely Created Check was not authorized by me with fraudulent intent or by any person acting in concert with me, and I have not received any benefit from the transaction. I acknowledge that, to the extent my account is credited for the amount of the Remotely Created Check, ABC Bank will have the right to recover all amounts so paid from the person who created the Remotely Created Check, and to bring a criminal and/or civil action against such person, if it so elects. I further acknowledge that as part of its investigation, ABC Bank may need to disclose the contents of this Written Statement to third parties, and I hereby consent to such disclosure. I also acknowledge that to complete its investigation, ABC Bank may require further information concerning the matters set forth herein, which I agree to provide. I agree to cooperate in any internal or other investigation and/or legal action taken with regard to this matter. I further agree to testify, declare, depose, or certify to the truth of any or all of the foregoing before any competent tribunal, officer, or person, in any case now pending or that may be instituted in connection with this matter. Please provide a detailed narrative statement of the circumstances surrounding this claim (attach additional pages if needed): I hereby declare under penalty of perjury that the foregoing is true and correct. ___________________________________________________________________ ___________________________________________________________ Signature Date |
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