Member FDIC | Equal Housing Lender
Privacy Statement
Written Statement of Unauthorized Electronic (ACH) Debit
Submitter Information
Customer name/address
| Customer name |
|
| Customer address |
|
| City, State, Zip |
Transaction information
| Debited account number |
|
| Amount of Debit |
|
| Date of debit |
|
| Payee (Party Debiting the Account) |
Statements
I, the undersigned, hereby state all of the following:
- I am an authorized signer or otherwise have the authority to act on the debited account described above.
- I have reviewed the circumstances of the electronic debit to the account, as described above.
- I have concluded the debit was not authorized.
- The debit was not originated with fraudulent intent by me or any person acting in concert with me.
The following, to the best of my knowledge, is the reason for that conclusion:
Date transaction authorized if the transaction was debited before authorized.
The amount authorized if the amount of the transaction was different from the amount I authorized.
Other information (if you chose the reason as OTHER above):
I have read the above statements in their entirety and certify that the statements and information provided are true and correct.
Today's date
Place (City)
County or Parish:
State
For Financial Institution Internal Use Only:
Date Financial Institution first notified: ________________________________________
Received by: ____________________________________________________________