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]
Account Holder Name: [Full Name]
Account Number: [Account Number]
Type of Account: [Checking / Savings / Other]
Bank Name: [Bank Name]
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If applicable, authorization was revoked on: [Date]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]
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]
