Bank Account Levy / Freeze Activity Log (Free PDF)

Track each freeze or levy on your bank account with dates, amounts, creditors, and follow-up so you can request exemptions or dispute errors.

Account details

Record who was levied, which bank, and the period you're tracking.

Account holder name

Primary bank name

Time period covered

Total levied (optional estimate)

Summary notes

Log each freeze or withdrawal with the amount and creditor.

Event date

Bank name

Account last 4

Creditor name

Court case number

Amount frozen/taken

Exempt funds description

Bank notice reference

Follow-up actions

Notes

Calculated total levied from entries: 0.00

This is a personal recordkeeping tool and not official bank or legal documentation.