Written Statement of Unauthorized Debit (ACH)

Member Number

Checking Savings

Member Name

Daytime Telephone Number

Amount of Debit

Date of Debit

Company Debiting the Account

Must match the description exactly as shown on your statement.

After examining my statement or other notification from the credit union, an ACH debit entry was charged to my account number listed above and I state that the ACH Debit was unauthorized.

I did not authorize the debit to my account. (R10)

I do not know or did not authorize the party listed above to debit my account. The signature of a check that was processed electronically is not my signature.

I authorized the party listed above to debit my account, but the entry does not conform to the terms of my authorization. (R11)

My account was debited before the date that I authorized. My account was debited for an amount different than I authorized. My check was improperly processed electronically. Incomplete Transaction (Example: My account was debited but my other Financial Institution did not receive the credit).

I did authorize the party listed above to debit my account, but: (R07)

I revoked the authorization I had given to the party to debit my account before the debit was initiated. I wish to stop any future debits connected with this revoked authorization I have multiple disputes with the same company. I have entered the amount and date of each transaction below.

Amount and Date of Transaction #1

Amount and Date of Transaction #2

I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the ACH debit transaction above was not originated with fraudulent intent by me or any person acting in concert with me, and that the signature below is my own proper signature.

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

___________________________________________
Authorized Signature

_______________________
Date

Star One Credit Union use only

Received by (Operator Name & ID)

Date

Rev: 03/08/2023

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