Unauthorized ACH Debit (Direct Account Info)

Statement of Unauthorized ACH Debit

Have you contacted the company debiting your account?

Yes

No

If you have not contacted the company debiting your account, please do so before filling out this document.

If yes, please write a summary of what action they advised you to take.

Account/Transaction Information

Name *

Enter Valid Phone Number *

Account Number *

Amount of Debit *

Date of Debit *

Party Debiting the Account *

Statement

I (the undersigned) hereby attest that (i) I have reviewed the circumstances of the above electronic debit (ACH) to my account and (ii) the debit was not authorized, and (iii) to the best of my knowledge the following is the reason for that conclusion:

I did not authorize the party listed to debit my account

I revoke the authorization I had given the party before my account was debited

My account was debited before the date I authorized

My account was debited for a different amount than what I authorized

My check was improperly processed electronically

Other (Must specify)

If other, please specify here

Submit