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<Opening - Unresolved>

<Transaction Grid>

To expedite processing of your claim, please complete, sign and return the attached affidavit We are in the process of investigating your request of the unauthorized or revoked ACH activity that occurred on your account.

Additional information is required in order for us to complete our investigation. Please review and sign the attached Written Statement of Unauthorized Debit form and return to the address below within 7 10 business days.


<ReturnAddress>


<Print Footer>

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