Written Statement of Unauthorized Debit – ACH Dispute

* Required Fields

Account/Transaction Information

Name:* Account Number:* Email:* Originator/Company Debiting the Account

Date $ Amount

Statement

I, (the undersigned) state that I have examined my statement (or other notification) from EP Federal Credit Union indicating that the ACH debit entry (entries) listed above was charged to my account and that the entry was unauthorized, improper, incomplete, or a prior authorization was revoked.

I further state that: (select one)

Unauthorized – (R10; R05 if CCD/CTX to consumer account)

I did not authorize the Company listed above to debit my account

I Authorized but – (R11)

I authorized the Company listed above to originate the specified debit entry to my account, but (select one)

The amount debited is different than the amount I authorized.

The amount I authorized is $

The debit was made to my account on a date earlier than the date on which I authorized the debit to occur.

I authorized the debit to be made to my account on (no earlier than)

The amount debited was not credited to the agreed upon payee.

The name of the payee to be credited was

The party above exceeded the permissible attempts to collect.

Authorization Revoked – (R07, PPD, TEL, WEB, IAT, & POS)

I authorized the company listed above to originate the specified debit entry to my account, but on I revoked that authorization by notifying the Company.

Check(s) Converted to ACH are improper due to the following reason

(R11, R51) I was not provided the required notice.

(R10, R51) The signatures on the item are not authentic or authorized, and/or the item has been altered.

(R11, R51) The amount of the entry is different from the amount of the check.

(R11 R51) The item is ineligible to be initiated as an ACH entry.

(R37, R53) Both the check and the ACH entry posted to my account.

Authorization

I further state that the debit transaction was not originated with fraudulent intent by me or by any person acting in concert with me, I am an authorized signer or have authority to act on this account, and the signature below is my own proper signature. I certify [under penalty of perjury] that the foregoing is true and correct.

Signature:

Date:

Please allow two business days for processing. Payments past 60 days may not be eligible for recovery.

Written Statement of Unauthorized Debit – ACH Dispute

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Statement

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Written Statement of Unauthorized Debit – ACH Dispute

Account/Transaction Information

Statement

Authorization

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