ACH Dispute Form

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Written Statement of Unauthorized Debit (ACH)

* Required Fields

1. Account/Transaction Information

Member Number:

Member Name:

Primary Phone Number:

Email Address:

Preferred Method of Contact:

Phone

Date of Transaction :

/ /

Amount of Transaction:

Merchant Name:

2. Statement

I (the undersigned) hereby attest that (i) I have reviewed the circumstances of the above electronic (ACH) debit to my account, (ii) the debit was not authorized, and (iii) 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 check was improperly processed electronically.

Other (must specify below)

3. Signature

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 me or any person action in concert with me.

I have read this statement in its entirety and attest the information provided on this statement is true and correct.

Signature (use mouse or finger):

Date:

/ /

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