unauthorized debit ach business form
Rev 4/15 • Member FDIC
Please complete a Business ACH Electronic Statement for requesting the return of an unauthorized corporate ACH debit entry SEC code
of CCD or CTX only.
The Business ACH Electronic Statement must be signed and dated on or after the posting date of the entry(ies) for which credit is
being requested.
An unauthorized debit means an electronic fund transfer (ACH) from a business account initiated by a person or company who
was not authorized by the business via an authorization that was either signed or similarly authenticated, to initiate the transfer.
Account/Transaction Information
Business Name (and/or DBA Name): Business Phone: Federal Tax ID Number:
Business Account Number:
Date of Debit: Amount of Debit: SEC Code: Party Debiting Account:*
* As identified on the account statement.
I (the undersigned) hereby attest that (1) I have reviewed the circumstances of the above electronic (ACH) debit(s) to the business account listed, (2)
the debit entry(ies) for SEC code of CCD or CTX was not authorized, and (3) the following, to the best of my ability to identify, is the reason for that
Please select one option below. Reason selected must apply to all transactions, if not you must submit separate form(s):
q The business did not authorize the party listed above to debit the account.
q The business revoked the authorization the business had given to the party listed above to debit the account before the debit was initiated.
q The business account was debited before the date the business authorized the transaction to occur.
q The business account was debited for an amount different than authorized.
q A business check was improperly processed electronically.
q Other (must specify):
Customer Authorization and Signature
I am an authorized signer, or otherwise have authority to act, on the business account identified in this statement. I attest that the debit(s) above was
not originated with fraudulent intent by the business or any person acting in concert with the business. I have read this statement in its entirety and
attest that the information provided on this statement is true and correct and that the signature below is my own proper signature and acknowledge
receipt of a copy, which should be retained for the business account records.
I acknowledge that if I have reported this to Flagstar Bank beyond one banking day after the original posting date of the unauthorized entry(ies), that
Flagstar Bank can only return the item(s) provided the Originating Depository Financial Institution has agreed to accept the late return entry(ies).
Authori zed Signer s Name:
Authorized Signer’s Signature: Date:
Once complete and signed, please mail, email, or fax to:
Mail: Card Services | Mail Stop 4-316 | 301 W. Michigan Avenue
Jackson, MI 49201 Email: Disputes@flagstar.com Fax:
For internal use only
Employee Name:
Phone: Branch #:
Business Account Number
Business Account Number
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