Written Statement of Unauthorized ACH Debit Template: WSUD

Written Statement of Unauthorized ACH Debit Template: WSUD

Written Statement of Unauthorized ACH Debit Template: WSUD

Written Statement of Unauthorized ACH Debit Template: WSUD

Typical length: 4-6 pages

Length: 4-6 pages

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Written Statement of Unauthorized ACH Debit Template


Account Holder Name: [Full Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]

Date: [Date]

To: [Bank or Financial Institution Name]
Branch or Department: [Department Name, if applicable]
Address: [Address]


1. Account Information

Account Holder Name: [Full Name]
Account Number: [Account Number]
Type of Account: [Checking / Savings / Other]
Bank Name: [Bank Name]


2. Transaction Information

I am disputing the following ACH debit transaction:

Company Name / Originator: [Company Name]
Transaction Date: [Date]
Transaction Amount: [$Amount]
Transaction Description or Reference: [Description / Reference Number, if known]

If more than one transaction is being disputed, list additional transactions here:

[Insert additional transaction details]


3. Statement of Unauthorized Debit

I state that the ACH debit identified above was unauthorized or otherwise improper for the following reason:

☐ I did not authorize this debit
☐ I revoked authorization before the debit occurred
☐ the amount debited was different from the amount authorized
☐ the debit was made on a date different from the date authorized
☐ the debit was for a different receiver or purpose than authorized
☐ other: [Describe]

Additional explanation:

[Insert explanation]


4. Authorization or Revocation Details

If applicable, the original authorization was given on: [Date]

If applicable, authorization was revoked on: [Date]

Method of revocation, if any:

☐ written notice
☐ phone call
☐ email
☐ in person
☐ other: [Describe]

Additional details regarding authorization or revocation:

[Insert details]


5. Supporting Information

The following supporting information or documents may be attached:

☐ copy of account statement
☐ copy of written revocation
☐ copy of authorization, if available
☐ correspondence with company
☐ other: [Describe]


6. Account Holder Certification

I certify that the information provided in this Written Statement of Unauthorized ACH Debit is true and correct to the best of my knowledge.

I understand that this statement may be used by the financial institution in reviewing my claim regarding the ACH debit listed above.


7. Signature

Account Holder Signature: __________________________
Name: [Full Name]
Date: [Date]


8. Bank Use Only

Claim Reference Number: [Reference Number]
Date Received: [Date]
Reviewed By: [Name / Department]
Action Taken: [Insert action]

Written Statement of Unauthorized ACH Debit Template


Account Holder Name: [Full Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]

Date: [Date]

To: [Bank or Financial Institution Name]
Branch or Department: [Department Name, if applicable]
Address: [Address]


1. Account Information

Account Holder Name: [Full Name]
Account Number: [Account Number]
Type of Account: [Checking / Savings / Other]
Bank Name: [Bank Name]


2. Transaction Information

I am disputing the following ACH debit transaction:

Company Name / Originator: [Company Name]
Transaction Date: [Date]
Transaction Amount: [$Amount]
Transaction Description or Reference: [Description / Reference Number, if known]

If more than one transaction is being disputed, list additional transactions here:

[Insert additional transaction details]


3. Statement of Unauthorized Debit

I state that the ACH debit identified above was unauthorized or otherwise improper for the following reason:

☐ I did not authorize this debit
☐ I revoked authorization before the debit occurred
☐ the amount debited was different from the amount authorized
☐ the debit was made on a date different from the date authorized
☐ the debit was for a different receiver or purpose than authorized
☐ other: [Describe]

Additional explanation:

[Insert explanation]


4. Authorization or Revocation Details

If applicable, the original authorization was given on: [Date]

If applicable, authorization was revoked on: [Date]

Method of revocation, if any:

☐ written notice
☐ phone call
☐ email
☐ in person
☐ other: [Describe]

Additional details regarding authorization or revocation:

[Insert details]


5. Supporting Information

The following supporting information or documents may be attached:

☐ copy of account statement
☐ copy of written revocation
☐ copy of authorization, if available
☐ correspondence with company
☐ other: [Describe]


6. Account Holder Certification

I certify that the information provided in this Written Statement of Unauthorized ACH Debit is true and correct to the best of my knowledge.

I understand that this statement may be used by the financial institution in reviewing my claim regarding the ACH debit listed above.


7. Signature

Account Holder Signature: __________________________
Name: [Full Name]
Date: [Date]


8. Bank Use Only

Claim Reference Number: [Reference Number]
Date Received: [Date]
Reviewed By: [Name / Department]
Action Taken: [Insert action]

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Learn more about

Written Statement of Unauthorized ACH Debit Template: WSUD

Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.

Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.

WRITTEN STATEMENT OF UNAUTHORIZED ACH DEBIT TEMPLATE FAQ


What is a written statement of unauthorized ACH debit?

A written statement of unauthorized ACH debit, often called a WSUD, is a document used by an account holder to state that an ACH debit entry was unauthorized or improper. It is commonly used when money was taken from a bank account without proper authorization, after authorization was revoked, on the wrong date, or in an amount different from what was authorized. The statement helps the bank review the claim and process the dispute under applicable payment rules.


Why do you need a written statement of unauthorized ACH debit?

You need a written statement of unauthorized ACH debit to give your bank a clear written record of why the ACH debit is being disputed. It helps identify the transaction, explain the basis of the claim, and confirm that the account holder is formally stating that the debit was unauthorized or otherwise not properly permitted. A written form also supports internal bank review and recordkeeping.


When should you use a written statement of unauthorized ACH debit?

Use a written statement of unauthorized ACH debit when an ACH transaction was taken from your account without valid authorization or in a way that did not match the authorization you gave. It is commonly used when a recurring payment continues after revocation, when the amount differs from what was approved, when the debit was made too early, or when the account holder never authorized the debit at all.


How to write a written statement of unauthorized ACH debit?

Start with the account holder’s name, account details, and contact information. Then identify the ACH debit transaction, including the company name, date, and amount, and clearly explain why the debit was unauthorized. After that, include any revocation details or related notes and finish with the account holder’s certification, signature, and date so the statement is complete and ready to submit to the bank.


Can AI Lawyer help if banking staff, account holders, and compliance teams all need to review?

AI Lawyer can help by organizing the statement into clear sections so each reviewer can find the relevant details quickly. It can also add reference fields, notes, and placeholders that make updates easier to track. A consistent structure helps reduce repeated edits and lowers the chance of missing key details like debit dates, company names, dispute reasons, or account holder certification before the form is submitted.

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