Affidavit Of Unauthorized Ach Form

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AFFIDAVIT OF UNAUTHORIZED ACH
409 Silverside Road, Suite 105
Wilmington, DE 19809
Written Statement of Unauthorized Debit (ACH)
I, _________________________________, state that I have examined my statement or other notification from The Bancorp Bank/
The Bancorp HSA indicating that an ACH debit entry was charged to my Account No. ____________________, on ________________,
20___ in the amount of $____________________, and that the debit was unauthorized or improper.
An unauthorized debit (with the exception of TEL entries) means an electronic fund transfer from a consumer’s account initiated
by a person who was not authorized by the consumer, via a writing that was either signed or similarly authenticated, to initiate the
transfer. With respect to TEL entries, an unauthorized debit means an electronic fund transfer from a consumer’s account initiated
by a person who was not authorized by the consumer, via an oral authorization, to initiate the transfer.
An electronic fund transfer in an amount greater than that authorized by the consumer or that results in a debit to the consumer’s
account earlier than that authorized by the consumer also is an unauthorized debit. An unauthorized debit does not include an
electronic fund transfer initiated with fraudulent intent by the consumer or any person acting in concert with the consumer.
An improper debit means a Re-presented Check Entry [RCK], Point-of-Purchase Entry [POP], or Accounts Receivable Entry [ARC]
that meets the criteria described in Part 3 below.
PART 1: Unauthorized Entries
For unauthorized entries, I further state that: (check one)
I did not authorize, and have not ever authorized, _____________________(company name) to originate one or more ACH entries to
o
debit funds from my account.
I authorized _____________________(company name) to originate one or more ACH entries to debit funds from my account,
o
but on _____________________, 20_____ I revoked that authorization by notifying _____________________ in the manner
specified in the authorization.
I authorized __________________ to originate one or more ACH entries to debit funds from my account at but the amount debited is
o
different than the amount I authorized to be debited. 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
o
made to my account on or no earlier than _______________, 20______.
PART 2: Incomplete Entries
Incomplete entry:
o My account was debited but the corresponding payment was not made to the intended third-party payee.
PART 3: Improper Entries
For improper entries, I further state that: (check one)
* for RCK entries:
the item to which the entry relates is ineligible to be initiated as an RCK entry;
o
the required notice stating the terms of the re-presented check entry policy was not provided by the Originator in accordance with
o
the requirements of the NACHA Operating Rules;
all signatures on the item to which the RCK entry relates are not authentic or authorized, or the item has been altered;
o
the amount of the RCK entry was not accurately obtained from the item; or
o
both the RCK entry and the item to which the RCK entry relates have been presented for payment.
o
* for ARC entries:
notice was not provided by the Originator in accordance with the requirements of the NACHA Operating Rules;
o
the source document used for the debit entry is improper;
o
both the source document and the ARC entry to which it relates have been presented for payment; or
o
the amount of the ARC entry was not accurately obtained from the source document.
o
* for POP entries:
the debit entry for which the Receiver is seeking recredit was not authorized by the Receiver;
o
the source document used for the debit entry is improper; or
o
both the source document and the POP entry to which it relates have been presented for payment.
o
(Continue to Part 4 on next page)
044
11/2014

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