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The Written Statement of Unauthorized Debit is required to support ACH claims. It is typically included with the confirmation letter as an attachment/enclosure, but can also be sent manually from the Communication Hub. When it is sent manually, it will include a cover letter.


Applies ToCard
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Relates To

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Cover Letter Content

<Manual Header>

<Opening - Unresolved>

<Transaction Grid>

To expedite processing of your claim, please complete, sign and return the attached affidavit to the address below within 7 days.


<ReturnAddress>


<Print Footer>

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To expedite processing of your claim, please complete, sign and return the attached affidavit to the address below within 7 days.


Quavo Financial Services
Attention: Card Operations
P.O. Box 12345
East Lansing, MI 48820-1234


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Statement Content

STATEMENT OF DISPUTE


RE: Case <CaseNumber> for account ending in <AccountLast4>


I, <CustomerName>, hereby dispute the transaction(s) listed below for the following reason:


Merchandise or services not received.
I was charged for the transaction listed, but I have not received the merchandise or service. I expected to receive _____________________________________________________ from the merchant on __/_/_. I contacted the merchant on ___/_/__, and their response was _______________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________.

Cash not received at ATM.
The ATM did not dispense the cash I requested or dispensed a partial amount. The amount dispensed by the ATM was _______________________.

Credit not processed.
I was promised a credit for the transaction listed and it has not been processed. Attached is a copy of the credit transaction receipt or voided transaction receipt.

Paid for by other means.
Attached is a copy of the front and back of the canceled check/cash receipt/money order/bank statement or proof of other payment by other means.

Transaction value not loaded.
The value loaded to the card for this transaction is incorrect. The amount that should have been loaded is _______________________.


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Please provide any additional information you believe may be helpful in our investigation (you may attach additional pages, if needed):



I certify that, to the best of my knowledge and belief, all the information on this Statement is true, correct, complete and made in good faith.


Signature: _________________________________________________ Date: ___________________