Statement of Unauthorized ACH Debit

* Indicates Required

• Account/Transaction Information

  Member Name*

  Email*

  Phone *

  Member Number*

  Amount of Debit*

  Date of Debit*

  Name of Party Debiting the 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) the following, to the best of my ability to identify, is the reason for that conclusion:*

  Select one of the following:*

  A reason is required

  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 for an amount different than I authorized. My check was improperly processed electronically. I wish to place a stop payment and understand that a fee applies. Other (must specify):

  When selecting other, please provide a reason below.

  
  

• 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.

  Member Name (type name)*

  Date*

  Member Signature*

  Clear Signature