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Run: Overdraft Reg E Opt-In Confirmation Form

This Overdraft Reg E Opt-In Confirmation Form records a consumer’s affirmative election for ATM and one-time debit card overdraft coverage, plus the required...

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Consumer and Account Identification

Consumer Full Name (required)

Deposit Account Number (Last 4 Digits) (required)

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. (required)

Transactions Covered by This Election (required)

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. (required)

Yes No N/A

Disclosure Acknowledgment

I received and reviewed the Regulation E overdraft service disclosure before making this election. (required)

Yes No N/A

I understand that I may revoke this opt-in at any time by contacting the financial institution. (required)

Yes No N/A

Preferred Method for Revocation Notice

Optional. This does not limit your right to revoke by any permitted method.

Consent and Attestation

Consumer Signature (required)

Date Signed (required)

Internal Notes

Internal use only. Record any relevant audit trail details, such as delivery method of the disclosure or assisted completion notes.

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