Member FDIC - Equal Housing Lender

Privacy Statement

Unauthorized ACH Form
Submitter Information (Required)
First Name
(required)
Last Name
(required)
Resolve the errors marked in red before submitting again.
Contact Information
Phone Number:Email Address:

 
Mailing Address

We will not update our records with this information. If this information needs updated, please submit an "address/contact change form".

Contact Preference
If we have questions about this form, how would you like us to contact you? (required)
Dispute Information
Account Number:
Transaction Date:
Payee (party debiting the account):
Please list any additional details:
Select the Appropriate Error Reason
Date Authorized:
Amount Authorized:

This form must be signed to submit the transaction(s) as unauthorized.  After submitting this form you will receive a secure email and/or mail via the USPS.

 

By completing this form, I attest to 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 above, to the best of my knowledge, is the reason for that conclusion.