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Cover Letter Content
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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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 |
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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)
- I wish to stop any future debits connected with this revoked authorization
- 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.
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WRITTEN STATEMENT OF UNAUTHORIZED DEBIT |
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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
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- 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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IV. Signature I am an authorized signer, or otherwise have the authority to act, on the account identified in this statement. I attest that the |
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debit above was not originated ___________________________________________________________________ ___________________________________________________________ |
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Account Owner / Joint Signature Date |
Br: ___________________________________ Tlr: _____________________________________
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Any intentional attempt to obtain money from a financial institution by misrepresenting whether a transaction was authorized may result in the imposition of fines up to Please sign and return within 10 business days to your nearest Quavo branch or mail to: Quavo Financial Services, Attention: ACH Operations, P.O. Box 12345, |
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