Written Statement of Unauthorized Debit

Member Name: *

Member Number: *

Amount of Debit: *

Date of Debit: *

Party Debiting Account: *

Select the option that best fits your reason for dispute: *

I did not authorize the transaction.

I revoked authorization prior to the above transaction.

My account was debited before the date I authorized.

My account was debited for an amount different than I authorized.

I did authorize the party listed above to debit my account, but they have exceeded the permissible attempts to collect.

Thank You for Submitting Your Written Statement of Unauthorized Debit Request.

A CU Member Service Representative will be contacting you shortly to complete this process.