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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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I. Account Information
| Full Name | <CustomerName>Steve Rogers |
| Account Number | |
| Claim Number | <CaseNumber> |
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- 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)
- I wish to stop any future debits connected with this revoked authorization
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Please sign and return within 10 business days to your nearest <ClientName> Quavo branch or mail to: <ACHOpsAddress>: Quavo Financial Services, Attention: ACH Operations, P.O. Box 12345,
East Lansing, MI 48820-1234. If not returned, your request may not be honored.
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