Description	The Written Statement of Unauthorized Remotely Create Check is required to support fraud Check claims. It is included with the confirmation letter as an attachment/enclosure. The statement section of the form will be pre-selected, based on the answers provided during intake.
Applies To	Check
Relates To
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Statement Content

WRITTEN STATEMENT OF UNAUTHORIZED REMOTELY CREATED CHECK

Member Name (First, Last): <Customer Name>                                

Address:                              <Street Address>                                   

                                            <City, State, Zip Code>                          

Telephone Number:            <Phone Number>                                  

I am the owner of the account #                        at <Institution Name>. A remotely created check no. dated as of <Check Date>, made payable to in the amount of <$XX.XX> (“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, <Institution Name> 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, <Institution Name> 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, <Institution Name> 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):

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

___________________________________________________________________                           ___________________________________________________________ 

Signature                                                                                                                  Date

Statement Sample

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 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.