Written Statement of Unauthorized ACH Debit
I, , state that I have examined my statement or other notification
from Inspirus Credit Union, a division of Gesa Credit Union, indicating that an ACH debit entry from
(Company Name)
was charged to my Account #_____________, on (date) _____________ in the amount(s) of
$______________, and the debit was unauthorized, revoked or improper. The funds were debited from
my account within the last 60 (sixty) days, and should be returned for the following reason(s):
Unauthorized or Improper
I did not authorize the debit either in writing, verbally or electronically with this company.
I authorized the debit, but for a different amount, or on a later date.
Improper Item (check(s) converted to electronic item was improper for the following reason):
a) Notice not provided
b) More than 180 days old
c) For more than $2,500
d) Debit presented for more than three times e) Source document forged or altered
Both the Check and ACH Debit entry were presented for payment. (duplicate payment)
Revoked authorization for recurring payments
I authorized this company to debit my account, but revoked that authorization in the manner
Specified in the original authorization on (date) ___________________.
I further declare that the debit transaction was not originated with fraudulent intent by me or any person
acting in concert with me, that the signature below is my own proper signature, and that I have authority to
act on behalf of this account. I further declare that if I am consumer contesting an unauthorized corporate
entry, that I am not using this consumer account for business purposes. I agree that a copy of this
statement may be provided to the above company if requested.
I certify under penalty of perjury that the foregoing is true and correct.
(Signature) (Date)
Note: For questions or clarification, please contact the ACH Department at 1-888-628-4010.
If multiple debits from the same company are being returned please list each date and
dollar amount above.