Written Statement of Unauthorized Debit (ACH)To help get your money back faster, please fill this out completely, print, and send it back.

1. Account & Transaction Information

Name of Customer:

Account Number:

Amount of Debit: Must match the transaction amount in question, showing exact dollars & cents.

Date of Debit: Must match the date that the money was removed from your account.

Merchant's Name: Must match the merchant's name that shows on your account statement.

I never authorized the merchant listed above to debit my account.

I revoked the authorization I had given to the merchant listed above, before the debit was initiated.

My account was debited before the date I authorized.

My account was debited for an amount that was different from what I authorized.

My check was improperly processed electronically.

My account was debited by a Third Party Sender who did NOT complete the corresponding payment to the merchant I transacted with.

3. Signature

Signed

Date Signed (Must be on or after the Date of Debit, above)

I agree that this electronic signature shall serve as the equivalent of my own.

After completing all sections, please print this form and FAX it to (866) 358-0526. Or scan and E-mail it to disputedocuments@netspend.com

2. Statement

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

I (the undersigned) hereby attest that (a) I have reviewed the circumstances of the above ACH debit to my account; (b) the debit was not authorized; and (c) The following reason is why I make this determination. (Please select only ONE reason)

Thank You !