Ach Dispute Form - Written Statement Of Unauthorized Debit - Usc Credit Union
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1ACH DISPUTE FORM
Written Statement of Unauthorized Debit
Name: __________________________________
Account #: ___________________
TRANSACTION INFORMATION
Amount of Debit: _______________
Date Debit Posted to Account: _______________
Party Debiting the Account: _____________________________________________________
………………………………………………………………………………………………………
I (the undersigned) hereby attest that:
• I have reviewed the circumstances of the above electronic debit to my account,
• the debit was not authorized, 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 recurring payment authorization I had given to the party to debit my
account before the debit was initiated.
Can include pre-authorized payments or deposits
(PPD), international ACH transactions (IAT) or recurring internet-authorized entries (WEB).
I wish to stop any future debit connected with this revoked authorization.
My account was debited before the date I authorized.
My account was debited for an amount different from what I authorized.
My check was improperly processed electronically.
Other (please specify) _______________________________________________
………………………………………………………………………………………………………
I am an authorized signer, or otherwise have authority to act, on the account identified in this
statement. I attest that the debit above was not originated with fraudulent intent by my 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.
Signature: __________________________________
Date: __________________
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