Written Statement of Unauthorized Debit (ACH) Form

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Form Instructions

Not to be completed for transactions performed with a Debit or Credit Card or a Bill Pay payment.

Please complete, print, sign, date and mail this application to:

Star One Credit Union
Attn: Support Services
P.O. Box 3643
Sunnyvale CA 94088-3643

Your Information

Date of Request:

mm/dd/yyyy

Member Number:

Checking

Savings

Member Name:

Daytime Telephone Number:

Amount of Debit:

Date of Debit
(Format: mm/dd/yyyy):

Company Debiting the Account:

Must match the description exactly as shown on your statement.

Unauthorized Entries. I further state that, after examining my statement or other notification from the credit union, an ACH debit entry was charged to my account number listed above and I state that the ACH Debit was unauthorized for the following reason:

	I did not authorize the party listed above to debit my account.
	I revoked the recurring authorization I had given to the party to debit my account before the debit was initiated.
	My account was debited on a different date than I authorized.
	My account was debited for an amount different than I authorized.
	My check was improperly processed electronically.
	Incomplete transaction (Example: My account was debited but my other Financial Institution did not receive the credit).

I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the ACH debit transaction above 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.

I have read this statement in its entirety and attest that the information provided on this statement is true and correct.

___________________________________________
Authorized Signature

_______________________
Date

Star One Credit Union use only
Received by (Operator ID and Initials):
Date:

Rev: 07/01/2014