Written Statement of Unauthorized Debit (ACH)
Written Statement of Unauthorized Debit 04/19/2019
Account/Transaction Information Account Type:_________
Account Number
Amount of Debit
Date of Debit
Party Debiting Account
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 party listed above to debit my account.
I revoked the authorization I had given to the party to debit my account before the
debit was initiated.
My account was debited before the date I authorized.
My account was debited for an amount different than I authorized.
My check was improperly processed electronically.
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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