Written Statement of Unauthorized Debit

Written Statement of Unauthorized Debit (ACH)

Full Name

Account Number

Amount of Debit

Date of Debit

Party Debiting the Account

Statement

I did not authorize the party listed above to debit my account.

I revoked the authorization I had given to the party 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 that I authorized.

My check was improperly processed electronically.

Incomplete Transaction: My account was debited, but the corresponding payment was not credited to my account with the party listed above.

I did authorize the party listed above to debit my account, but they have reinitiated this debit to my account more than two times.

Other (Secify)

Signature

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 me or any person acting in concert with me. I have read this statement in its entirety and attest that the information provided on this statement is true and correct.

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

September 26, 2021 9:28 pm PDT

Written Statement of Unauthorized Debit Uploaded by Adam McGee - hello@lemonheaddesign.com IP 50.207.9.75

November 28, 2021 10:50 pm PDT

California Community Credit Union - backoffice@caccu.org added by California Community Credit Union - thestaff@caccu.org as a CC'd Recipient Ip: 67.199.161.80

November 10, 2022 1:13 pm PDT

California Community Credit Union - backoffice@caccu.org added by Adam McGee - hello@lemonheaddesign.com as a CC'd Recipient Ip: 50.207.9.75