Written Statement of Unauthorized Debit (ACH)
Name: Account Number:
Amount of Debit: $ Date of Debit:
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:
My check was improperly processed electronically
My account was debited before the date I authorized.
I revoked the recurring payment authorization I had given to the party to debit my account before the debit was initiated.
I did not authorize the party listed above to debit my account.
My account was debited for an amount different than I authorized.
1. Account/Transaction Information:
2. Statement:
3. 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.
Signature:
Date:
Party Debiting the Account:
2805 Bowers Ave
Santa Clara CA, 95051
Email To: DisputeForm@keypointcu.com OR
Fax To: (408) 731-4068
Amount of Debit: $ Date of Debit:
Amount of Debit: $ Date of Debit:
Party Debiting the Account:
This form may be used to dispute multiple transactions. If you require additional lines, you may include here, on a separate sheet, or submit another form.
Amount of Debit: $ Date of Debit:
Party Debiting the Account:
I wish to stop any future debits connected with this revoked authorization.
Incomplete Transaction: My account was debited, but the payment was never received by the intended recipient.
Party Debiting the Account:
