Written Statement of Unauthorized Debit (ACH)
Revised 04/20
Account/Transaction Information Account Type:
N
ame
Account Number
Amount of Debit
Date of Debit
Party Debiting 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) following, to the best of my ability to identify, is the reason for this conclusion
I did not authorize the debit to my account
I do not know or did not authorize the party listed above to debit my account.
The signature of a check that was processed electronically is not my signature.
I authorized the party listed above to debit my account, but the entry does not
conform to the terms of my authorization.
My account was debited before the date I authorized.
My account was debited for an amount different than I authorized.
My account was debited by an authorized third party, but that third party failed
to m
ake my payment as instructed.
My check was improperly processed electronically.
A debit to my account that was previously returned was improperly reinitiated.
I authorized the party listed above to debit my account, but:
I revoked the authorization I had given to the party to debit my account before
the debit was initiated.
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.
Authorized Signer Date
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signature
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