ACH Check Scam
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 |
