Written Statement of Unauthorized Debit (ACH) - ACE Elite Prepaid Account · 2020-03-26 · Written...

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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 [email protected] 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 !

Transcript of Written Statement of Unauthorized Debit (ACH) - ACE Elite Prepaid Account · 2020-03-26 · Written...

Page 1: Written Statement of Unauthorized Debit (ACH) - ACE Elite Prepaid Account · 2020-03-26 · Written Statement of Unauthorized Debit (ACH) To help get your money back faster, please

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 [email protected]

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 !