Adverse Action Form – Fill Out and Use This PDF

Chex Systems, Inc.

Notice of Adverse Action Form Samples

Release Date: January 2012

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customers certain sample adverse action forms, procedures, or other similar information (collectively, Materials . ChexSystems customers acknowledge and agree that the Materials were created for general

application and have not been customized to address usto ers’ specific business operations. ChexSystems does not guarantee that the Materials will comply with any applicable laws, rules or regulations, and the customer is responsible for its use of Materials and bears sole liability for any such use.

Samples in this document include:

1.ChexSystems Adverse Action Notice, without Credit Score Disclosure

2.ChexSystems Adverse Action Notice, with Credit Score Disclosure

3.ChexSystems, plus Credit Bureaus Adverse Action Notice, with Credit Score Disclosure

CHEXSYSTEMS POSITION ON THE CREDIT SCORE DISCLOSURE REQUIREMENT

ChexSystems is not taking a position on whether or not its customers are required to provide the Credit Score Disclosure to declined account applicants; rather, each financial institution is responsible for making this determination on its own behalf. As a convenience to its customers that elect to provide the Credit Score Disclosure to declined account applicants, ChexSystems is now making available the data fields necessary to support the Credit Score Disclosure requirements set forth by the Dodd-Frank Act. These additional data fields are provided in the ChexSystems QualiFile electronic inquiry response.

Chex Systems, Inc. (herein ChexSystems) is a consumer reporting agency and

an indirect wholly owned subsidiary of Fidelity National Information Services, Inc.

Notice of Adverse Action

Notice Date:

We are sorry but we are unable to accommodate your request to open a deposit account with our institution at this time. Our decision was based in whole or in part on information obtained in a report from the consumer reporting agency listed below. You have a right under the Fair Credit Reporting Act to know the information contained in your file at the consumer reporting agency. The reporting agency played no part in our decision and is unable to supply specific reasons why we have denied your request to open a deposit account in our institution. You also have a right to a free copy of your report from the reporting agency, if you request it no later than 60 days after you receive this notice. In addition, if you find that any information contained in the report you receive is inaccurate or incomplete, you have the right to dispute the matter with the reporting agency.

Chex Systems, Inc.

Attn: Consumer Relations

7805 Hudson Road, Suite 100

Woodbury, MN 55125

Telephone: 800-428-9623

Fax: 602-659-2197

Web: www.consumerdebit.com

If you have any questions regarding your consumer report, you should contact the consumer reporting agency using the contact information above.

If you have any other questions regarding this notice, you should contact:

Institution name:

Institution address:

Institution toll-free telephone number:

As a convenience, Chex may provide or otherwise make available to Client certain sample adverse action forms, procedures, or other similar information (collectively,

Materials ). Clie t a k o ledges a d agrees that the Materials ere reated for ge eral appli atio a d ha e ot ee usto ized to address Clie t’s spe ifi business operations. Chex does not guarantee that the Materials will comply with any applicable laws, rules or regulations, and Client is responsible for its use of Materials and bears sole liability for any such use.

Notice of Adverse Action

Notice Date:

We are sorry but we are unable to accommodate your request to open a deposit account with our institution at this time. Our decision was based in whole or in part on information obtained in a report from the consumer reporting agency listed below. You have a right under the Fair Credit Reporting Act to know the information contained in your file at the consumer reporting agency. The reporting agency played no part in our decision and is unable to supply specific reasons why we have denied your request to open a deposit account in our institution. You also have a right to a free copy of your report from the reporting agency, if you request it no later than 60 days after you receive this notice. In addition, if you find that any information contained in the report you receive is inaccurate or incomplete, you have the right to dispute the matter with the reporting agency.

Chex Systems, Inc.

Attn: Consumer Relations

7805 Hudson Road, Suite 100

Woodbury, MN 55125

Telephone: 800-428-9623

Fax: 602-659-2197

Web: www.consumerdebit.com

We also obtained your credit score from this consumer reporting agency and used it in making our credit decision. Your credit score is a number that reflects the information in your consumer report. Your credit score can change, depending on how the information in your consumer report changes.

Scores range from a low of 100 to a high of 9999

Key factors that adversely affected your credit score (insert here the four key factors that adversely affected the credit score or if the number of recent inquiries is a key factor, insert five key factors including the number of recent inquiries):

If you have any questions regarding your credit score, you should contact the consumer reporting agency using the contact information above.

If you have any other questions regarding this notice, you should contact:

Institution name:

Institution address:

Institution toll-free telephone number:

As a convenience, Chex may provide or otherwise make available to Client certain sample adverse action forms, procedures, or other similar information (collectively,

Materials ). Clie t a k o ledges a d agrees that the Materials ere reated for ge eral appli atio a d ha e ot ee usto ized to address Clie t’s spe ifi

business operations. Chex does not guarantee that the Materials will comply with any applicable laws, rules or regulations, and Client is responsible for its use of Materials and bears sole liability for any such use.

Notice of Adverse Action

Notice Date:

We are sorry but we are unable to accommodate your request to open a deposit account with our institution at this time. Our decision was based in whole or in part on information obtained in a report from one or more of the consumer reporting agencies listed below. You have a right under the Fair Credit Reporting Act to know the information contained in your file at the consumer reporting agency. The reporting agency played no part in our decision and is unable to supply specific reasons why we have denied your request to open a deposit account in our institution. You also have a right to a free copy of your report from the reporting agency, if you request it no later than 60 days after you receive this notice. In addition, if you find that any information contained in the report you receive is inaccurate or incomplete, you have the right to dispute the matter with the reporting agency.

business operations. Chex does not guarantee that the Materials will comply with any applicable laws, rules or regulations, and Client is responsible for its use of Materials and bears sole liability for any such use.

Sample Form Continues on Next Page….

We also obtained your credit score from this consumer reporting agency and used it in making our credit decision. Your credit score is a number that reflects the information in your consumer report. Your credit score can change, depending on how the information in your consumer report changes.

Scores range from a low of 100 to a high of 9999

Key factors that adversely affected your credit score (insert here the four key factors that adversely affected the credit score or if the number of recent inquiries is a key factor, insert five key factors including the number of recent inquiries):

If you have any questions regarding your credit score, you should contact the consumer reporting agency using the contact information above.

If you have any other questions regarding this notice, you should contact:

Institution name:

Institution address:

Institution toll-free telephone number:

As a convenience, Chex may provide or otherwise make available to Client certain sample adverse action forms, procedures, or other similar information (collectively,

Materials ). Clie t a k o ledges a d agrees that the Materials ere reated for ge eral appli atio a d ha e ot ee usto ized to address Clie t’s spe ifi business operations. Chex does not guarantee that the Materials will comply with any applicable laws, rules or regulations, and Client is responsible for its use of Materials and bears sole liability for any such use.