Cover Letter Content

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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 Written Statement of Unauthorized Debit form and return to the address below within 10 business days.

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Cover Letter Sample

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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 Written Statement of Unauthorized Debit form and return to the address below within 10 business days.

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

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Statement Content

WRITTEN STATEMENT OF UNAUTHORIZED DEBIT (ACH)

I. Account Information

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II. Transaction Information

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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.

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View file name WSURCC (1).pdf

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Panel bgColor #F4F5F7 Sample WRITTEN STATEMENT OF UNAUTHORIZED REMOTELY CREATED CHECK Member Name (First, Last): Steve Rogers                                       Address:                              123 Main Street                                                                               Evanston                        , IL  12345     Telephone Number:            (111) 222 - 1234                                  I am the owner of the account # 1234567890         at ABC Bank. A remotely created check no. 0011            dated as of 07/01/2024, made payable to in the amount of $500.00 (“Remotely Created Check”), was drawn on my account. I hereby certify that the issuance of the Remotely Created Check was not authorized by me with regard to either the amount stated on the Remotely Created Check, the payee stated on the Remotely Created Check, or both. I further certify that the Remotely Created Check was not created at my request, approval or direction, nor did I otherwise indicate my consent to the creation of the Remotely Created Check. I also certify that the Remotely Created Check was not authorized by me with fraudulent intent or by any person acting in concert with me, and I have not received any benefit from the transaction. I acknowledge that, to the extent my account is credited for the amount of the Remotely Created Check, ABC Bank will have the right to recover all amounts so paid from the person who created the Remotely Created Check, and to bring a criminal and/or civil action against such person, if it so elects. I further acknowledge that as part of its investigation, ABC Bank may need to disclose the contents of this Written Statement to third parties, and I hereby consent to such disclosure. I also acknowledge that to complete its investigation, ABC Bank may require further information concerning the matters set forth herein, which I agree to provide. I agree to cooperate in any internal or other investigation and/or legal action taken with regard to this matter. I further agree to testify, declare, depose, or certify to the truth of any or all of the foregoing before any competent tribunal, officer, or person, in any case now pending or that may be instituted in connection with this matter. Please provide a detailed narrative statement of the circumstances surrounding this claim (attach additional pages if needed):

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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)

I. Account Information

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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.

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I hereby declare under penalty of perjury that the foregoing is true and correct. ______________________________

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_____________________________________

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___________________________________________________________

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Signature                                                                                                                  Date

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