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We are in the process of investigating your request of the unauthorized or revoked ACH activity that occurred on your accountthe claim referenced above.

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

<ReturnAddress><ACHOpsAddress>

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To expedite processing of your claim, please We are in the process of investigating the claim referenced above.

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

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

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Statement Content

WRITTEN STATEMENT OF DISPUTE

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UNAUTHORIZED DEBIT (ACH)

I. Account Information

II. Transaction Information

III. Statement

I (the undersigned) hereby attest that (i) I have reviewed the circumstances of the above electronic (ACH) debit(s) to my account, (ii) the debit(s) were 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 Originating Company listed above to debit my account

• •  I revoked the recurring payment authorization I had given the Originating Company to debit my account before the debit was initiated

• • •  I wish to stop any future debits connected with this revoked authorization
       (Stop will be placed for a period of 13 months and Stop Payment Fee will be accessed)

• •  My account was debited before the date I authorized
  •  My account was debited for an amount different from what I authorized
  •  My check was improperly processed electronically

IV. Signature

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

___________________________________________________________________                           ___________________________________________________________ (Verbal / In Person)

Account Owner / Joint Signature                                                                            Date

                                                                                                                                Br: ___________________________________ Tlr: _____________________________________

                                                                                                                                Confirmation: ____________________________________________________________.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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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: ___________________

Please sign and return within 10 business days to your nearest <ClientName> branch or mail to: <ACHOpsAddress>. If not returned, your request may not be honored.