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Sample ChexSystems Report
Sent to you by mail when you request a copy from ChexSystems

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[DATE OF REPORT]

[YOUR NAME HERE]
[YOUR STREET ADDRESS HERE]
[CITY STATE ZIP]

Dear [YOUR NAME HERE]:

Reported Information:

Name:     [YOUR NAME HERE AS REPORTED BY INSTITUTION]
Address:  [ADDRESS AS REPORTED BY INSTITUTION]
          [CITY, STATE, & ZIP AS REPORTED BY INSTITUTION]
SSN/ID#:  [YOUR SS# AS REPORTED BY INSTITUTION]
Source of Information: [INSTITUTION NAME]
                       [INSTITUTION CITY, STATE]
RTN #: [ABA-BANK ROUTING #]  Account #: [YOUR A/C# AT BANK]
Date Reported: [DATE INSTITUTION FILED REPORT]
Reported For: [REASON (e.g., "NON-SUFFICIENT FUNDS (NSF) ACTIVITY")]

 (The above section gets repeated for each incident.)

Inquiries Made:
Name:  [YOUR NAME HERE]
SSN/ID#: [YOUR SS# AS REPORTED BY INQUIRING INSTITUTION]
Financial Institution Obtaining Report:
      [INSTITUTION NAME]
      [INSTITUTION CITY, STATE]
Date:  [DATE INQUIRY MADE]

 (Chex says they only show to financial institutions the
  requests made within the last 90 days.
The above section gets repeated for each inquiry.) Retail Information / Source: [INSTITUTION NAME (e.g., "Shared Check Auth. Net - SCAN")] [INSTITUTION ADDRESS, CITY, STATE, ZIP] [INSTITUTION PHONE] [NOTES (e.g., "Drivers License # xxxxx" on file w/SCAN, or "Returned Unpaid Checks: ..." on file w/SCAN)] (The above section gets repeated for each retail source.) Drivers License Validation / Made Available By Each State [DRIVERS LICENSE VALIDATION INFO (e.g., "Drivers license number xxxxx is a valid format for the state of XX", Some states will show name and date of birth.)] (The above section gets repeated for each state.) Social Security Validation / Source: [INSTITUTION NAME (e.g., "The Social Security Adminisitration")] [INSTITUTION CITY, STATE] [NOTES (e.g., "SS#: 999-99-9999 Became Available for Issuance in 19xx in the State of XX")] (The above section gets repeated for each source.) In any future contact with us, please include the following consumer ID: [YOUR CHEX ID#] for [YOUR NAME]. Sincerely, ChexSystems (footing for each page follows:) Letter ID: [CHEX LETTER ID#] Agent ID: [CHEX AGENT ID#] [PAGE #]
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