REQUEST FORM
Note to Consumer
You have the right to obtain a free copy of your consumer information file report every 12 months (also known as an "Annual File Disclosure").
Your CrossCheck file report may contain information on check writing history, which may be used by CrossCheck to make decisions on whether to authorize a check. Your file report is not provided or disclosed to any third party as part of this process.
For more information on obtaining your free file report, visit www.cross-check.com/consumers-check-writers, call 1-800-843-0760 or write to CrossCheck, Inc., Attn: Consumer Inquiry Department, P.O. Box 6008, Petaluma, CA 94955-6008.
By submitting this request, you hereby affirm that you are the person on whose behalf this consumer file report inquiry is being made and that all the information herein submitted is true and correct to the best of your knowledge.
You should receive a copy of your file report within 15 days of submitting a complete request.
You are submitting this form for:
An Annual Report, or
Inquire about a specific check authorization.
ANNUAL REPORT
The following information is required to process your request for your annual file disclosure:
(Required fields are indicated by
*
)
You are submitting this request as
an individual or, as
a business.
First Name:
Last Name:
*
Business Name:
*
First Name:
*
Last Name:
*
Phone Number:
*
Email:
*
Confirm Email:
*
ID Number:
*
State of Issuance:
Military
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Address/Line 1:
Address/Line 2:
*
City:
*
Zip:
*
State:
-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
CHECK AUTHORIZATION
If you are requesting a file disclosure in reference to a check authorization, your request must include the following additional information:
Number of Checks:
1
2
3
4
5
6
Check 1
*
Check Number:
Check Date:
Check Amount:
*
Routing Number:
*
Account Number:
Check Is Issued To:
Check 2
*
Check Number:
Check Date:
Check Amount:
*
Routing Number:
*
Account Number:
Check Is Issued To:
Check 3
*
Check Number:
Check Date:
Check Amount:
*
Routing Number:
*
Account Number:
Check Is Issued To:
Check 4
*
Check Number:
Check Date:
Check Amount:
*
Routing Number:
*
Account Number:
Check Is Issued To:
Check 5
*
Check Number:
Check Date:
Check Amount:
*
Routing Number:
*
Account Number:
Check Is Issued To:
Check 6
*
Check Number:
Check Date:
Check Amount:
*
Routing Number:
*
Account Number:
Check Is Issued To:
.