Phone (310) 618-9111 | Location ATM Locator
Routing # 322283152 |
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Unauthorized Debit Form

Account/Transaction Information

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Statement

I (the undersigned) hereby attest that (1) I have reviewed the circumstances of the above electronic (ACH) debit to my account, (2) the debit was not authorized, and (3) the following, to the best of my ability to identify, is the reason for the conclusion:

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Select an option for a list of scenarios and check below which one best describes your situation(*)
Select an option for a list of scenarios and check below which one best describes your situation
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The item to which the represented check (RCK) entry relates was ineligible because (check one)
The item to which the represented check (RCK) entry relates was ineligible because (check one)
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The item to which the accounts receivable (ARC) entry relates was ineligibile because (check one)
The item to which the accounts receivable (ARC) entry relates was ineligibile because (check one)
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The item to which the point-of-purchase (POP) entry relates was ineligible because (check one)
The item to which the point-of-purchase (POP) entry relates was ineligible because (check one)
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Both the electronic and paper items have been presented. (RCK, ARC, POP)

Amount was not accurately obtained from the source document.(RCK and ARC only)

The notice stating the terms of the policy was not provided to me in advance of receiving the item to which the represented check entry or accounts receivable entry relates.(RCK and ARC only)

All signatures on the original item are not authentic or authorized.(RCK only)

The original item has been altered. (RCK only)

Signature

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 me or any person acting in concert with me.

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

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