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The Written Statement of Unauthorized Debit is required to support ACH claims. It is |
typically included with the ACH confirmation letter as an attachment/enclosure, but can also be sent manually from the Communication Hub. When it is sent manually, it will include a cover letter. The statement section of the form will be pre-selected, based on the answers provided during intake. | Applies To | ACH |
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Cover Letter Content
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We are in the process of investigating |
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the claim referenced above. Additional information is required in order for us to complete our investigation. Please |
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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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To expedite processing of your claim, please complete, sign and return the attached affidavit to the address below within 7 days.
Quavo Financial Services
Attention: Card Operations
P.O. Box 12345
East Lansing, MI 48820-1234
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Statement Content
STATEMENT OF DISPUTE
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Quavo Financial Services
Attention: Card Operations
P.O. Box 12345
East Lansing, MI 48820-1234 | Multiexcerpt fast include block macro |
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WRITTEN STATEMENT OF UNAUTHORIZED DEBIT I. Account Information Full Name | Steve Rogers | Account Number | 56781234 | Claim Number | 2407030001C |
II. Transaction Information Originating Company | Debit Amount | Transaction Date |
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PAYPAL VERIFY | $5.00 | 11/01/2019 |
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.
- My account was debited before the date I authorized.
- My account was debited for an amount different from what I authorized.
- My account was debited by a third party, but the third party failed to make the payment as instructed.
- I was charged/credited more than once.
- A debit/credit to my account that was previously returned was improperly reinitiated
- 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 that 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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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.
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Account Owner / Joint Signature Date 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
$1,000,000, or imprisonment up to 30 years, or both under the provisions of Federal law (18 U.S.C. § 1344) 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,
East Lansing, MI 48820-1234. If not returned, your request may not be honored. |
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