Please complete one form for each disputed item.
Questions or need assistance completing this form? Please contact us at (800) 678-8765. If you prefer fax or email a PDF version of this form, click here to Download/Print a PDF.
An ACH debit can be considered unauthorized if: you never authorized the ACH debit entry from this account; you authorized an ACH debit from this account, but the debit amount is different than the amount authorized; or it was posted earlier than the date authorized.
You authorized the ACH debit but revoked the authorization, in accordance with your agreement with the Payee Company named above, prior to the date the debit posted to your account.
You authorized the ACH debit, but the payee did not receive the funds.
The Check I Wrote was Improperly Converted to an ACH Debit. The following are scenarios that could be considered as improper conversions of your check:• Both your check and an ACH debit were presented for payment from your account.• You did not receive a notice stating that your check may be converted or re-presented as an ACH debit.• Your check that was converted to an ACH debit was altered, the signatures were not authentic or authorized, or the amount used was not the same as the written check amount.
Please allow two business days for processing. Transactions past 60 calendar days are not eligible for dispute. Please submit one (1) form per disputed item. Incomplete forms / errors will delay the credit.
I certify that by signing this Written Statement of Unauthorized Debit, that I am an authorized signer or otherwise have the authority to act on the account identified in this statement. This debit transaction was not initiated with fraudulent intent by me or any person acting on my behalf. That the information provided on this statement is true and correct, and that the signature below is my proper signature.