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Cover Letter Content

<Manual Header>

<Opening - Unresolved>

<Transaction Grid>

We are in the process of investigating the claim referenced above.

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We are in the process of investigating the claim referenced above.

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Statement Content

WRITTEN STATEMENT OF 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: _________________________________________________________________

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. 

Statement Sample

WRITTEN STATEMENT OF UNAUTHORIZED DEBIT (ACH)

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