Unauthorized Debit (ACH)

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Member Information

Today's Date*

Account Number*

Account Holder Name*

Amount of Debit*

Date Debit Posted to Account*

Party Debiting the Account*

Statement

I (the undersigned) hereby attest that (i) I have reviewed the circumstances of the above electronic (ACH) debit to my account, (ii) the debit was not authorized, and (iii) the following, to the best of my ability to identify, is the reason for that conclusion:*

I did not authorize the party listed above to debit my account

I revoked the recurring payment authorization I had given to the party to debit my account before the debit was initiated

Can include pre-authorized payments or deposits (PPD), international ACH transactions (IAT) or recurring internet-authorized entries (WEB).

Choose One*

I wish to stop any future debits connected with this revoked authorization

My account was debited before the date I authorized

My account was debited for an amount different from what I authorized

My check was improperly processed electronically

Other

Other (Please Specify)*

Signature

I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the debit above was not originated with fraudulent intent by me or any person acting in concert with me. I have read this statement in its entirety and attest that the information provided on this statement is true and correct.

Note: Your account is subject to a $10.00 ACH Stop Payment Fee.

Signature*

Date*

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