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Last Updated: August 13, 2014
Petition for Exception to
Returned Check Charge
PERSONAL INFORMATION
FIRST NAME: ___________________ LAST NAME: _________________________
MI: _____ UVID: __________________
STREET: __________________________________________________ CITY: ________________ STATE: _____
ZIP: _______
PHONE: ________________ CELL PHONE: ________________ EMAIL ADDRESS:
___________________________________
CHECK AMOUNT: ______________ CHECK NUMBER: ___________ WRITTEN FOR: ________________________________
EXPLANATION
FULLY EXPLAIN YOUR REASON AND JUSTIFICATION FOR THIS PETITION:
AGREEMENT
In accordance with 7-15-1, Utah Code Annotated, an issuer of a check (payment instrument) is liable to the holder
of the check if the check is not honored at the time it is presented; and is marked “refer to maker”; the account
upon which the check is made or drawn: does not exist; has been closed; or does not have sufficient funds or
sufficient credit for payment in full of the check; or the check is issued in partial or complete fulfillment of a valid
and legally binding obligation; and the issuer stops payment on the check with the intent to: fraudulently defeat a
possessory lien; or otherwise defraud the holder of the check. The issuer of the check is liable for the check amount
and a returned check charge of $20.
Exceptions to the return check charge are only considered if the check was returned in error by your financial
institution. This must be documented by your financial institution on official letterhead and signed by the branch
manager. The original letter must be included with this petition form.
I certify that I have read and fully understand the above and request an exception to the return check policy. If this
return check was an electronic check payment, I am aware that I agreed to the online terms. I affirm, to the best of
my knowledge, that the statements I provided are true. Submission of the petition form does not guarantee
approval.
Signature: _____________________________________________________________________________ Date: ___________
Original bank documentation MUST be included with this form to support your claim.
This must be on your financial institution’s official letterhead and signed by the branch manager.
Com
leted forms with su
ortin
documentation must be submitted within 15 da
s of check return.
RETURN COMPLETED FORM TO:
CONTACT INFORMATION:
Mailing Address: In Person:
P: 801.863.8611
Utah Valley University
Collections Office – MS 109
800 W. University Parkway
Orem, UT 84058-6703
Room BA-011 E: collect@uvu.edu
FOR OFFICE USE ONLY:
APPROVED
DENIED
OFFICE STAFF: _____________
