ACH Affidavit

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Affidavit of Unauthorized / Improper ACH Debit Activity

State of ____________________ County of _______________________

_____ I _____________________ authorized __________________________ to

originate one or more ACH entries to debit funds from my Account No. ______________, but on _______________, 20___ I revoked that authorization by notifying _______________________ in the manner specified in their authorization. (For reoccurring debits)

OR

I, _______________________________, depose and say that I have examined the attached statement or other notification from [ ] indicating that an ACH debit entry was charged to my Account No. _________________, on _______________, 20___ in the amount of $__________, and that the debit was unauthorized or improper.

I. For unauthorized entries, I further depose and say that: (check one)

_____ I did not authorize, and have not ever authorized, in writing, signed or similarly authenticated________________________ to originate one or more ACH entries to debit funds from any account at [ ].

_____ I authorized __________________________ to originate one or more ACH entries to debit funds from my account, but on _______________, 20___ I revoked that authorization by notifying _______________________ in the manner specified in the theirauthorization.

_____ I authorized __________________________ to originate one or more ACH entries to debit funds from an account at ( ) but _____ the amount debited exceeds the amount I authorized to be debited. The amount I authorized is $__________.

or

_____ the debit was made to my account on a date earlier than the date on which I authorized the debit to occur. I authorized the debit to be made to my account on or no earlier than __________ ,20__.

II. For improper entries, I further depose and say that: (check one)

_____ (a) The notice stating the terms of the re-presented check entry policy was not provided to me in advance of receiving the item to which the re-presented check entry relates.

_____ (b) The item was ineligible because either: (check appropriate reason)

_____ the item to which the re-presented check entry relates is not an item within the meaning of Revised Article 4 of the Uniform Commercial Code (1990 Official Text);

_____ the item to which the re-presented check entry relates is not a negotiable demand draft drawn on or payable through or at a Participating DFI, other than a Federal Reserve Bank or Federal Home Loan Bank;

_____ the item to which the re-presented check entry relates is in an amount of $2,500 or more;

_____ the item to which the re-presented check entry relates does not indicate on the face of the document that the item was returned due to "Not Sufficient Funds," "NSF," "Uncollected Funds" or comparable language;

_____ the item to which the re-presented check entry relates is dated more than 180 days from the date the entry is transmitted to the RDFI;

_____ the item to which the re-presented check entry relates is drawn on a non-consumer account

_____ the item to which the re-presented check entry relates has been previously presented (a) more than twice in paper form (for initial re-presented check entries) or (b) more than once in paper form and more than once as a re-presented check entry(for reinitiated re-presented check entries).

_____ (c) All signatures on the item to which the re-presented check entry relates are not authentic or authorized.

_____ (d) The item to which the re-presented check entry relates has been altered.

I further depose and say that the debit transaction was not originated with fraudulent intent by me or any person acting in concert with me, and that the signature below is my own proper signature.

Dated: ________________________

Print Name _______________________

Signature: ________________________


Unauthorized ACH Entries

Debit Fraud Reversals

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