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Employee No.
Date Sent to Image
/ /
Access No.
Print Name
Signature
Date (MM/DD/YY)
Member Name
Checking Account Number
Posting Date (MM/DD/YY)
Dollar Amount
Payee/Company Name
© 2020 Navy Federal NFCU 50 (5-20)
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
For Office Use Only
Navy Federal
®
Written Statement of Unauthorized Debit
• Fill out the form as completely and accurately as possible. A complete form will improve our ability to investigate your claim.
• Automated Clearing House (ACH) rules require a Written Statement of Unauthorized Debit before an unauthorized debit may be returned.
To expedite your request, please return the completed form to a branch, fax it to Navy Federal at (703) 255-7969, email it to nfcu_form50@
navyfederal.org, or send it as an attachment in an eMessage through Navy Federal Online Banking or mobile app. If you are unable to
fax, send by eMessage, send by email, or return the form to a branch, you may mail your signed, completed form to Navy Federal at the
following address: Navy Federal Credit Union, ATTN: Funds Services, P.O. Box 3000, Merrifield, VA 22119-3000. If you are disputing a
Bill Pay (BP) transaction, contact Fiserv directly at 1-888-560-8031.
Written Statement of Unauthorized Debit
I have examined the account statement or other notification sent by Navy Federal Credit Union indicating that an ACH debit entry posted
to my account with the information below. The debit was unauthorized, incorrect, revoked, improper, incomplete, or was improperly converted.
Only one payee/company may be listed on the form. Additional payees/companies each require their own form.
Please select only one reason for your request.
The ACH debit was unauthorized.
An ACH debit can be considered unauthorized if you never authorized the ACH debit entry from this account.
The ACH debit was incorrect.
An ACH debit can be considered incorrect if you authorized an ACH debit from this account, but the debit amount is different than the
amount authorized; it was posted earlier than the date authorized; the third party failed to make your payment as instructed; or a debit
that was previously returned was improperly reinitiated.
The authorization for the ACH debit was revoked.
You authorized the ACH debit but canceled or revoked the authorization in accordance with your agreement with the Payee Company
named above, before the debit posted to your account. (This is not the same as a stop payment.)
The transaction was incomplete.
You authorized the ACH debit and the funds were taken from your account, but the payee did not receive the funds.
The check I wrote was improperly converted to an ACH debit.
The following are scenarios that could be considered as improper conversions of your check:
• Both your check and an ACH debit were presented for payment from your account.
• You did not receive a notice stating that your check may be converted or re-presented as an ACH debit.
• Your check that was converted to an ACH debit was altered; the signatures were not authentic or authorized.
• The dollar amount is different than what was written on the check.
I certify that this Written Statement of Unauthorized Debit is true and correct, that I am an authorized signer of, or otherwise have authority to
act on, the account identified in this statement, that the debit transaction was not initiated with fraudulent intent by me or any person acting in
concert with me, and that the signature below is my own proper signature.
If you need assistance completing this form, you may contact Navy Federal toll-free in the U.S. at 1-888-842-6328, visit navyfederal.org for
toll-free numbers when overseas, or call collect internationally at 1-703-255-8837.
Signature is required.
NOTE: Please allow two to three business days for processing. Payments past 60 days may not be able to be recovered,
but will still be investigated.
For Office Use Only
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