Retail Sales Approval and Adverse Action Receipts

Consumers have the right to decline signing the approval reciept in view of the service fee, in this case a VOID transaction would be submitted.

XYZ MERCHANT
12345 MAIN STREET
ANYTOWN, USA 12345
(123) 456-7890
May 14, 2024 02:38PM
CHECK: $100.00
SALE: $100.00
EFT REF #: 500123456
Approval #: xxxxxxxx
Certegy REF#: xxxxxxxxxxxxxxx
BANK: 036110011
ACCT: ******1298
CHK #: 1123

By signing below, you authorize Certegy and/or the Merchant to use the information from your check to make a one-time electronic funds transfer (EFT) or bank draft from the account listed above for the amount of the check, or to process this payment as a check transaction. The debit will usually occur within twenty-four (24) hours of the date of the receipt. You may terminate this authorization by calling Certegy at the number below in such time as to afford Certegy and your financial institution a reasonable opportunity to act on your request. Terminating this authorization does not affect your duty to pay your underlying obligation. You understand that this authorization is subject to applicable law and network rules.

If your payment is returned unpaid, you authorize Certegy and/or the Merchant to collect a Service Charge and/or the face amount of the check by EFT or using bank drafts from your account. The Service Charge will be $[xxxxxxx.xx].

YOU ARE ELECTRONICALLY SIGNING AND AGREEING TO THIS AUTHORIZATION AND AUTHORIZING US TO ELECTRONICALLY DEBIT YOUR ACCOUNT. YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO BE BOUND BY THE TERMS OF THIS AUTHORIZATION.

The Service Charge will be $[xxxxxxx.xx].

_________________________________
SIGNED:
THANK YOU,
ANY QUESTIONS, Call
(Insert Merchant Phone Number 1-XXX-XXX-XXXX)
MERCHANT COPY

*Signatures are to be stored and saved for two years by the processor

CashLine Adverse Action Receipt

XYZ MERCHANT
12345 MAIN STREET
ANYTOWN, USA 12345
(123) 456-7890
May 14, 2024 02:38PM
CHECK: $100.00
SALE: $100.00
Certegy REF#: xxxxxxxxxxxxxxx
BANK: 036110011
ACCT: ******1298

Certegy Payment Solutions, LLC (“Certegy”) provides authentication and risk management services to merchants and businesses nationwide.

Certegy did not make the decision to take adverse action and is unable to specify why we chose to decline the transaction.

Under the Fair Credit Reporting Act, you have the right to obtain a free copy of your information held in Certegy’s file, if you request it within the next 60 days. Also, if you find that Certegy’s records are inaccurate or incomplete, you have the right to dispute them with Certegy.

You may reach Certegy at www.askcertegy.com; toll free at 1-800-637-5747 or write to Certegy Payment Solutions, LLC, P.O. Box 908, Grand Junction, CO 81502