I, the undersigned, hereby state all of the following:
- I am an authorized signer or otherwise have the authority to act on the debited account described above.
- I have reviewed the circumstances of the electronic debit to the account, as described above.
- I have concluded the debit was not authorized.
- The debit was not originated with fraudulent intent by me or any person acting in concert with me.
The following, to the best of my knowledge, is the reason for that conclusion:(Select at least one)
OptionalOKI did not authorize the party listed above to debit my account. is required
OptionalOKBefore the debit was initiated, I revoked the authorization I had previously given to the party to debit my account. is required
OptionalOKMy account was debited before the date I authorized. I authorized the debit to be made on or no earlier than is required
OKOriginal date authorized is required
OptionalOKMy account was debited for an amount different than I authorized. The amount I authorized is is required
OKOriginal amount authorized is required
OptionalOKMy account was debited as I authorized, but the transaction was not completed in processing. The debited amount was not used to fund a corresponding payment to the party authorized to receive the funds. is required
OptionalOKMy check was improperly processed electronically is required
OptionalOKOther, please specify is required
OKOther is required