Form FR 3066c FR 3066c Check Sample Survey

FR 3066c
OMB No. 7100-0351
Approval expires December 31, 2015

CSS Survey Instrument
1. Does this image have a Payee Line field (i.e., the line indicating
to whom the check is written) and an amount?
 Yes
 No – (next image)

2. Is there a smaller picture of another check embedded within
the image?




Yes – (prompts Q3)
No – (skips to Q4)

3. Does the following sentence appear to the left of that image,
“This is a LEGAL COPY of your check. You can use it the
same way you would use the original check.”?
 Yes
 No

4. Are any of these words on the front of the check (check all
that apply)?
 Cashier's Check, Official Check, or Certified Check
 Money Order or Postal Money Order
 Gift Certificate
 Rebate
 Savings’s Bond
 Traveler’s Check
 WIC Check
 “Please post this payment on behalf of our mutual
customer”
 None of the above

Payer (wrote the check)
5. Does the Payer name or address have any of these? (Check all
that apply)

 One or more persons' full names (John Smith, John and
Mary Smith, John Smith, Inc.)

 Trust (no affiliation with a bank name), Trustee, Estate
 Inc., LLC, LTD, Co., NA, Corp., Corporation, Company,






USPS, Post Office, United States Postal Service








School, High School, Elementary, University, College, .edu

Fannie Mae, Freddie Mac, Federal Home Loan
Chamber of commerce
Port Authority, Water Authority, Power Authority, Transit
Authority, Department of
Apartment number (apt. #) NOT Suite # or Building #
Accounts Payable, Acct. Payable
Other business indicator
Other government indicator
NO -- None of the above

6. Based on the Payer name and address and the characteristics
of the check, can you definitively categorize the Payer as any
of these?
 Consumer (i.e., not a business or government)







Government
Business
Not Consumer – either business or government
Not Government – either business or consumer
Cannot determine

7. Payer's ZIP code:
-



Zip code not present

Payee (paid by the check)
8. Does the Payee Line (i.e., the line indicating to whom the check
is written) or the front of the check itself include an address
for the Payee?
 Yes
 No

Services, .com, Association, PC, .org

 Church, Temple, other religious affiliation
 Bank, Credit Union, Insurance
 Funds, Mutual, Mutual Fund, Mutual Company,
Investments, Investment Company, Investor’s Fund

 Initials of Business or Association (e.g. NAACP, AT&T)
 Tax ID #
 State of, City of, County of, Town of, Township of, Bureau
of, Municipality

 State Treasury, State Treasurer, County Treasurer, County
Commissioner, County Controller

 US Treasury, Federal Reserve Bank
 IRS, Internal Revenue Service, State Tax, County Tax, Tax
Commissioner, Tax Collector

 Court of, District of

9. Does the Payee name (or address, if present) have any of
these? (Check all that apply)

 One or more persons' full names (John Smith, John and
Mary Smith, John Smith, Inc.)

 Cash
 Trust (no affiliation with a bank name), Trustee, Estate
 Inc., LLC, LTD, Co., NA, Corp., Corporation, Company,
Services, .com, Association, .org







Church, Temple, other religious affiliation
Bank, Credit Union, Insurance
Initials of Business or Association (e.g. NAACP, AT&T)
Tax ID #
State of, City of, County of, Town of, Township of, Bureau
of, Municipality

 IRS, Internal Revenue Service, State Tax, County Tax, Tax
Commissioner, Tax Collector, US Treasury







Court of, District of









School, High School, Elementary, University, College, .edu

 Bottom row of numbers not present

USPS, Post Office, United States Postal Service
Fannie Mae, Freddie Mac, Federal Home Loan
Chamber of commerce
Port Authority, Water Authority, Power Authority, Transit
Authority, Department of

15. Does the symbol II

appear in the leftmost position of the
row of numbers at the bottom of the document?
 Yes
 No

Dr., Doctor, MD, DDS, DVM, PC, Specialist, -ologist
Apartment number (apt. #) NOT Suite # or Building #
Accounts Receivable, Acct. Receivable

16. Which ONE of the following best describes the Signature on

Other business indicator

the face of the check:

Other government indicator

 Hand-written or facsimile
 Name in printed type face
 Reads "No Signature Required"
 Reads “Signature on File”
 In place of the signature a phrase stating “Authorized by

NO -- None of the above

on the front…
10. Date of the check:

the depositor”, “Authorized by the Payer”, or “As
Authorized Signatory” is present

/





/

Date not present

 The signature field is blank.

11. Enter the Serial Number (aka Check Number) listed in the

17. Are any of these items handwritten on the check? (Check all

upper right hand corner of the check.

that apply)

 DL, driver's license, license
 Handwritten state initials (GA, CA, MI, etc.) followed by

If there is no serial number in the upper right hand
corner, look to the bottom-most row of numbers on
the check. If the first character on the left hand side
is a II symbol, then enter the number you see
between that symbol of the next II symbol.






…




Number not present



12. Dollar amount of the check:
$

ot present



,

Below the signature a phrase stating “Authorized by the
depositor”, “Authorized by the Payer”, or “Authorized
Signature” is present

or preceded by a number
Tax ID #
Account, (e.g. acct #) followed or preceded by a number
Phone number handwritten or circled on face of check
Birth date written on check (Note: Date will be 1990 or
earlier.)
Stamped form (generally on the back of the check) that is
filled in with handwritten characters
NO -- None of the above

on the back…
,

18. Are any of these words in the Payee endorsement? (Check

.

all that apply)
 One of more person’s full names
 Dollar Amount, Amount, $
 Store, Store #, register #, terminal #, branch #, location #,
DL, D/L, cash back
 Inc., LLC, LTD, Co., NA, Corp., Corporation, Company,
Services, .com, Association, .org
 Trust (no affiliation with a bank name), Trustee, Estate
 Church, Temple, Other religious affiliation
 Bank, Credit Union, Insurance
 Initials of a Business or Association (NAACP, AT&T)

Amount not present

13. Is the dollar amount in the Courtesy Amount field
handwritten?
 Yes
 No (Machine-printed)

14. Enter the 9-digit transit routing number. This number is in
the bottom-most row of numbers between the
symbols (include dashes):

and

1

 Yes
 No

 State of, City of, County of, Town of, Township of,
Bureau of, Municipality
IRS, Internal Revenue Service, State Tax, County Tax,
Tax Commissioner, Tax Collector, US Treasury
Court of, District of
USPS, Post Office, United States Postal Service
Fannie Mae, Freddie Mac, Federal Home Loan
Chamber of commerce
Port Authority, Water Authority, Power Authority, Transit
Authority, Department of
School, High School, Elementary, University, College,
.edu
Dr., Doctor, M.D., DDS, DVM, PC, Specialist,
–
ologist
Other business indicator
Other government indicator
NO -- None of the above













24. Based on the Payee name/address and endorsement, can you
definitively categorize the Payee as any of these?








Government
Business
Not Consumer – either business or government
Not Government – either business or consumer
Cannot determine

25. If Payee is business or government, mark which type:

 Power, gas, phone, cable, internet service provider, other
utility

19. Is the Payee endorsement handwritten?

 Bank, credit union, credit card company, financing

 Yes – Handwritten
 No – It's stamped / machine-printed
 Cannot find Payee endorsement






20. On the back, is the Payee endorsement perpendicular or
parallel to the writing on the front of the check?

 Perpendicular
 Parallel
 Cannot find Payee endorsement







21. Do the words "Absent(ee)” or “Absent Endorsed, ” “ABS
END GUAR,” “ABS END GTD,” “Credit to Payee,” “CR
to Payee,” or “Lack End GTD” or other permutation of
these words appear anywhere on the back of the check?
 Yes



 No





22. Input the number (typically 9 digits) found on the back of








the check that exists between > and < symbols. In the event
that more than one set of > < symbols appear, first look for
the endorsement with a bank name associated with it and
enter that number. If each set has a bank name associated
with it, then choose the set that has the earliest date. The
date will appear next to or just below the number between
the > < symbols.

>

Consumer

<

 Number not present

Categorizing Payee
23. Is the payee the same person as the payer:

2

company, mortgage company, leasing company, or
insurance company
Apartment complex, condos, leasing office
Supermarket or Drugstore
Convenience store
Department store, shoe store, apparel store, sporting goods,
jewelry store, electronics store, home improvement store,
furniture store, other retail store, casino, cataloger
Restaurant, bar, diner, fast food
Subscription, membership organization, club, newspaper,
homeowner’s association
Airline, travel agent, other travel
Charitable organization, church
State of, City of, County of, Town of, Township of, Bureau
of, Municipality
US Treasury, IRS, Internal Revenue Service, State Tax,
County Tax, Tax Commissioner, Tax Collector
Court
USPS, Post Office, United States Postal Service
Port Authority, Water Authority, Power Authority, Transit
Authority, Department of
School, High School, Elementary, University, College
Medical (e.g., hospital, doctor’s office, etc.)
NOT a business or government
Other business indicator
Other government indicator
Cannot determine