ELIGIBLE INSTITUTION IOTA ERROR REPORT FORM
To be completed by the institution for each IOTA account for which a remittance error was made.
ELIGIBLE INSTITUTION
Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact
*
Department
*
Telephone
*
-
Area Code
Phone Number
LAWYER/LAW FIRM
Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
IOTA Account Number
*
(Do not omit any numbers)
REMITTANCE INFORMATION
Reporting Period:
Actual Transaction
Reporting Period
Correct Transaction
Reporting Period
Interest Rate/Dividend:
Actual Transaction
Interest Rate/Dividend
Correct Transaction
Interest Rate/Dividend
Gross interest/dividend earned for period:
Actual Transaction
Gross interest/dividend earned for period
Correct Transaction
Gross interest/dividend earned for period
Permissible service charges/fees (if any) deducted:
IOTA Handling fee:
Actual Transaction
IOTA Handling fee
Correct Transaction
IOTA Handling fee
Per deposit charge:
Actual Transaction
Per deposit charge
Correct Transaction
Per deposit charge
Per check charge:
Actual Transaction
Per check charge
Correct Transaction
Per check charge
Fee in lieu of minimum balance:
Actual Transaction
Fee in lieu of minimum balance
Correct Transaction
Fee in lieu of minimum balance
Other (describe):
Other (describe):
Other (describe):
Other (describe):
Correct remittance due the Foundation
Actual remittance paid the Foundation
Date
-
Month
-
Day
Year
Date Picker Icon
Check number
Difference
Payable to:
Financial Institution (the Foundation will issue a refund)
Foundation (return your check with this form)
EXPLANATION
Authorized official
*
Name
*
Title
Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit
For assistance in completing this form, or for more information about IOTA, please visit the Foundation’s website at
www.TheFloridaBarFoundation.org
or call (407) 960-7000, toll-free (800) 541-2195 and ask for the IOTA Department.
Should be Empty: