ACH Data Breach Form

ODFI Information

Origination Depository Financial Institution ( ODFI ) submitting report

ODFI routing/transit number (RTN)

Submitting Person Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Contact Person Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Incident Information

What Originators and/or third party service providers were involved?

How many Receiving Depository Financial Institution ( RDFI ) routing and transit numbers were affected (estimate if necessary)?

What is the approximate cause of the breach incident (please check all that apply)?

Hacker accessed data

Insider malfeasance

Lost or stolen computer or other storage device

Other (explain):

What is the approximate cause of the breach incident - others (explain)

What is the approximate date of the breach incident?

Begin Date

Begin Date: Year

Begin Date: Month

Begin Date: Day

End Date

End Date: Year

End Date: Month

End Date: Day

What is the approximate size of the affected population whose data was breached?

What type of Consumer-Level ACH Data was exposed? (Check all that apply)

Bank account number together with bank routing/transit number

Other (explain):

What type of Consumer-Level ACH Data was exposed - other (explain)

How should RDFIs be notified of this breach?

ODFI will contact affected RTNs

NACHA should notify DFIs

Please attach a file of the RTNs that may be affected.

RTNs should be sorted numerically. The file must be in PDF format. The file must also include your Security Contact information
One file only.
10 MB limit.
Allowed types: pdf.