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, 2018 02:38PM
CHECK: $100.00
SALE: $100.00
EFT REF #: 500123456
Approval #: xxxxxxxx
Certegy REF#: xxxxxxxxxxxxxxx
BANK: 036110011
ACCT: ******1298
CHK #: 1123
I authorize the use of the information from my check to make a one-time electronic funds transfer (EFT) or bank draft from my account for the amount of the check, or to process this payment as a check transaction. If my payment is returned unpaid, I authorize [XYZ Merchant (if Self-Risk)] [Certegy Payment Solutions, LLC (for Warranty)] to collect a Service Charge and/or the face amount of the check by EFT or using bank drafts from my account.
The Service Charge will be $[xxxxxxx.xx].
NOTE: ($XXX.XX or the calculation noted above varies from state to state. For each Location, Certegy shall provide the applicable amount or the calculation, as the case may be, for the state in which that Location is located.)
_________________________________
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
Retail Sales Adverse Action Receipt
XYZ MERCHANT
12345 MAIN STREET
ANYTOWN, USA 12345
(123) 456-7890
May 14, 2018 02:38PM
CHECK: $100.00
SALE: $100.00
Certegy REF#: xxxxxxxxxxxxxxx
BANK: 036110011
ACCT: ******1298
CHK #: 1123
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 30046, Tampa, FL 33630-3036
