All required fields have an asterisk ( * ).
Credit Union Information
*CU Name:
*CU Fax: xxx-xxx-xxxx
*R&T #:
Your Contact Information
*First Name:
*Last Name:
*Phone: Extension:
Email:
Adjustment Information
Please Select Adjustment Type (Required)
Encode Error Paid Twice Not Our Item Source of Receipt
*Listed As: Difference:
*Should Be:
*Check #: *Member Name:
*Clear Date:
mm / dd / yy		 Clear Date:
mm / dd / yy
*Trace #: Trace #:
    (Paid Twice - 2nd presentment Information)
Reason for Adjustment
Debits or Credits
Debit Adjustment:    
Credit Adjustment:    
       
   
       
NOTE: Southeast Corporate accepts Debit or Credit Adjustments $25.00 and under for Duplicate Items only. This is in compliance with the Federal Reserve Bank changes effective 2/14/2005 and 8/31/2009.