written statement of unauthorized debit (ach) - ace elite prepaid account · 2020-03-26 · written...
TRANSCRIPT
Written Statement of Unauthorized Debit (ACH)To help get your money back faster, please fill this out completely, print, and send it back.
1. Account & Transaction Information
Name of Customer:
Account Number:
Amount of Debit: Must match the transaction amount in question, showing exact dollars & cents.
Date of Debit: Must match the date that the money was removed from your account.
Merchant's Name: Must match the merchant's name that shows on your account statement.
I never authorized the merchant listed above to debit my account.
I revoked the authorization I had given to the merchant listed above, before the debit was initiated.
My account was debited before the date I authorized.
My account was debited for an amount that was different from what I authorized.
My check was improperly processed electronically.
My account was debited by a Third Party Sender who did NOT complete the corresponding payment to the merchant I transacted with.
3. Signature
Signed
Date Signed (Must be on or after the Date of Debit, above)
I agree that this electronic signature shall serve as the equivalent of my own.
After completing all sections, please print this form and FAX it to (866) 358-0526. Or scan and E-mail it to [email protected]
2. Statement
I am an authorized signer (or otherwise have authority to act) on the account identified in this statement. I attest that the debit above was not originated with fraudulent intent by anyone acting in concert with me. I have read this statement in its entirety and attest that the information provided is true and correct.
I (the undersigned) hereby attest that (a) I have reviewed the circumstances of the above ACH debit to my account; (b) the debit was not authorized; and (c) The following reason is why I make this determination. (Please select only ONE reason)
Thank You !