usbavp,
It has been pointed out to me that you were probably asking about a form for the consumer to complete, not a form for responding to a consumer claim. There are no model or sample forms for a consumer to complete in the proposed regulation. It is doubtful that one will be included in the final regulation, even as as sample.
When a final regulation is issued, you will probably be bombarded by those ever-helpful forms vendors who will be anxious to sell you one. Hopefully, it is a form that you will need in very small quantities - it is yet to be seen that there will even be that many substitute checks or what percentage of those will generate claims.
Nevertheless, the form will be critical. If it is to be forwarded to another bank in support of your bank's claim, it is fair to assume the other bank will be anxious to find fault with its content and structure.
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In this world you must be oh so smart or oh so pleasant. Well, for years I was smart. I recommend pleasant.