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I, depose and say that I have examined the attached statement or other notification from (Bank) indicating that an ACH debit entry was charged to my Account No. , on , in the amount of $, and that the debit was unauthorized or improper.
An unauthorized debit (with the exception of TEL entries) means an electronic funds transfer from a consumer's account initiated by a person which 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 the amount greater than that authorized by the consumer or which 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 Prearranged Payment and Deposit Entry (PPD), Re- presented Check Entry (RCK), Point-of-Purchase Entry (POP), or Accounts receivable Entry (ARC) that meets the criteria described in Section 2 below.
1. For unauthorized entries, I further depose and say that: (check one)
I did not authorize, and have not ever authorized, in writing (company name) to originate one or more ACH entries to debit funds from any account at (Bank)
I authorized (company name) to originate one or more ACH entries to debit funds from my account, but on , 20 I revoked that authorization by notifying in the manner specified in the authorization.
to orignate one or more ACH entries to debit funds from an account at (Bank) but:
2. For improper entries, I further depose and say that: (check one)
I further depose and say that the debit transaction was not originated with fraudulent intent by more or any person acting in concert with me, and that the signature below is my own proper signature.
By checking this box and submitting this application electronically, I agree to the same terms that apply to a signed written statement.
Note: RDFIs should consult with legal counsel and rely on their own business judgment in determining what specific form the written statement under penalty of perjury should take.