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EDS AUTOMATIC ADJUSTMENT FORM

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					                             EDS AUTOMATIC ADJUSTMENT FORM


 Member Atm/Debit Card Number: __________________________________
        Account#:_____________
                                                                                 Share ID:
_____________


 Member Name: _________________________________________________                  Adjmt Amt:
$__________
                                                                                 Fees Amt:
$___________

 Effective Date: ____/____/____        Post Date: ______________

 Description of Atm Machine: ______________________________________

 Reason Why Member Requesting Adjustment:

 _____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________

 Today’s Date: ____/____/____          Provisional Credit Date: ____/____/____


 Representative Name: _______________________________           Date: _______________________

 Representative Signature: ____________________________

 Authorized By: ____________________________________            Date: _______________________

For Research Unit Only

Date Sent to EDS: ________________                      Total Amount $________________

Date Provisional Credit Given: __/__/__
        Other______________________________________

				
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posted:2/16/2010
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