Written Statement of Unauthorized Debit (ACH)

* Required Fields
1.  Account/Transaction Information
Preferred Method of Contact:

Date of Transaction :
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2.  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:

3.  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 action in concert with me.

I have read this statement in its entirety and attest the information provided on this statement is true and correct.

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