Written Statement Of Unauthorized Ach Debit Form

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NRL Federal Credit Union
Written Statement of Unauthorized ACH Debit
Name ___________________________________________
Account Number __________________________________
Amount of Debit __________________________________
Date of Debit ____________________________________
Party Debiting Account _____________________________
I, ___________________________________, hereby attest that I have reviewed the circumstances of the above electronic
(ACH) debit to my account, the debit was not authorized, the authorization has been revoked or the debit was improper, and the
following, to the best of my ability to identify, is the reason for that conclusion:
____I did not authorize the party listed above to debit my account.
____I revoked the authorization I had given to the party to debit my account before the debit was initiated.
____My account was debited before the date I authorized.
____My account was debited for an amount different than I authorized.
____My check was improperly processed electronically.
____Other____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I am an authorized signer, or otherwise have the authority to act, on the account identified in this statement. I attest that the debit
above was not originated with fraudulent intent by me or any person acting in concert with me. I have read this statement in its
entirety and attest that the information provided on this statement is true and correct.
____________________
_________________________________________________
Date
Signature
Credit Union Use Only
This form was received and verified to be correct by:
Teller Initials: ___________
Teller No. _________
Trace No.________________________________ (Operations Dept. Use Only) SEC Code ________ Return Code _____
Return Code 05: Unauthorized debit (used only for CCD or CTX)
Return Code 07: Authorization revoked (not used for ARC, BOC, POP or RCK entries)
Return Code 10: Member advises debit not authorized, improper or ineligible (not used for CCD or CTX)
NRL Federal Credit Union will retain this statement for six years from the date of the return entry.
Revised June 2012

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