Overdraft Reg E Opt-In Confirmation Form

Documents a consumer's affirmative opt-in to ATM and one-time debit card overdraft service under Regulation E, including required disclosures, consent, and revocation acknowledgment.

Consumer and Account Identification

• Consumer Full Name
• Deposit Account Number (Last 4 Digits)
  Enter only the last 4 digits of the account number.
• Email Address
  Optional. Used to send a copy of this confirmation if you request one.
• Phone Number
  Optional. Used only if we need to contact you about this election.

Opt-In Election

• I want the financial institution to authorize and pay overdrafts for ATM and one-time debit card transactions.
• Transactions Covered by This Election
  Select the transaction types you want covered by this opt-in.
• I understand that overdraft fees or other charges may apply if the institution pays these transactions.

Disclosure Acknowledgment

• I received and reviewed the Regulation E overdraft service disclosure before making this election.
• I understand that I may revoke this opt-in at any time by contacting the financial institution.
• Preferred Method for Revocation Notice
  Optional. This does not limit your right to revoke by any permitted method.

Consent and Attestation

• Consumer Signature
• Date Signed
• Internal Notes
  Internal use only. Record any relevant audit trail details, such as delivery method of the disclosure or assisted completion notes.