[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 #]