erse Returned Check Fee S S S S Financial Institution Name: Authorized Signature: Print Name: For Metavante Use Only Telephone # Date: aZ Bank* Sri . Agent* /S - 3 Ext. Completed by Verification Date Date 2.33.09% MtDSbc (12,1) Fax 1R9 requests to Collections, 608-240-7601; others to Acco