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State of

__________________________________

County of

__________________________________

I, ______________________________________ (consumer's name), depose and say that I have examined the attached statement or other notification from my financial institution  indicating that an ACH debit entry was charged to my account number: __________________________ in the name of _________________________on __________________________ (date) in the amount of $___________________________, and that the entry was unauthorized, improper, or a prior authorization was revoked.  For non-consumer accounts:  I further assert that I am an authorized signer on the above-referenced account or have corporate authority to act on the above-referenced account.

A revocation of authorization means that the written agreement with the originating company, which was signed or similarly authenticated to allow payments processed through the ACH network to be deposited in or withdrawn from an account at a financial institution, has been cancelled.  The account holder must revoke authorization directly with the originating company prior to the return of the debit.

FOR REVOKED AUTHORIZATION, I FURTHER DEPOSE THAT:                         (Return reason code = R07 )

              I authorized _______________________(‘the Company’) to originate one or more ACH entries to debit funds from      my account, but on _________________,20_____, I revoked that authorization by notifying the Company in the manner specified in the authorization.

An unauthorized debit means an electronic funds transfer was never properly authorized by the account holder. An ACH debit in an amount greater than that authorized by the account holder, or that occurs on an earlier date than that authorized, is also considered unauthorized.  An unauthorized debit does not include an electronic funds transfer initiated with fraudulent intent by the account holder or any person acting in concert with the account holder.

FOR UNAUTHORIZED ENTRIES, I FURTHER DEPOSE AND SAY THAT (check one)

(Use R10 for consumer SEC codes to consumer acct; use R05 for corporate SEC codes to consumer acct; use R29 for corporate SEC codes to corp. acct.)

I did not authorize, and have not ever authorized, in writing, or by similarly-authenticated means (for WEB, TEL, and POP), _________________________________ (company) to originate one or more ACH entries to debit funds from any account at this financial institution.

I authorized ____________________________ (company) to originate one or more ACH entries to debit funds from this account at my financial institution in writing or by similarly-authenticated means, but: 

        ___ the amount debited exceeds the amount I authorized to be debited.  The amount I authorized was                $________________;                                                             

        OR

         ____ the debit was made to this account on a date earlier than the date on which I authorized the debit to occur.  I authorized the debit to be made to this account no earlier than ___________________________,20_____.

An IMPROPER DEBIT means an RCK, ARC, BOC, or POP entry where the item to which the entry relates is ineligible, or other criteria related to notice, amount or authenticity of signature as described to the left are not met.  AN RCK, ARC, BOX, or POP entry is also considered improper if both the electronic and paper items have been presented for payment.  Account holders may also formally opt out of check conversion activity (ARC and BOC).

FOR IMPROPER ENTRIES (RCK, ARC, BOC AND POP), I FURTHER DEPOSE AND SAY THAT (check one):

 

 (A)  The item to which the re-presented check (RCK) entry relates was ineligible because (check one) (R51 for all)

       __the item is drawn on a non-consumer account.

       __the item is not within the meaning of Revised Article 4 of the Uniform Commercial Code (1990 Official Text – ineligible items include non-cash items; drafts drawn on the U>S> Treasury, a Federal Reserve Bank, a Federal Home Loan Bank, or state or local government; U. S. Postal Service money orders, non-U.S. currency items; third-party items; demand drafts; and third-party drafts without Receiver’s signature).

       __the item is not a negotiable demand draft drawn on, or payable through or at, a Participating Depository Financial             Institution other than a Federal Reserve Bank or Federal Home Loan Bank.

       __the item is in an amount of $2,500 or more.

       __the item does not indicate on the face of the document that it was returned due to Not Sufficient Funds, NSF, Uncollected        Funds, or comparable language.

       __the item does not contain a pre-printed serial number.

       __ the item is dated more than 180 days from the date the entry was transmitted to the RDFI.

       __the item has been presented more than three times in any combination of paper and electronic means, including the original presentment.

      

 (B) The item to which the account receivable (ARC) entry, back office conversion (BOC) entry, or point of purchase (POP) entry relates was ineligible because (check one):                   (R10 for all options)

       __the item contains an Auxiliary On-Us field in the MICR line.

       __the item is for an amount greater than $25,000.

       __the item was not completed and signed by the Receiver.

       __the item was not encoded in magnetic ink. (BOC only)

       __the item does not contain a pre-printed serial number.

       __the item is a third-party check; a demand draft or third-party draft that does not contain the signature of the Receiver; a credit card check or home equity line of credit check; a check drawn on an investment company; an obligation of a financial institution such as a traveler’s check, money order, cashier’s check, or official check; a check drawn on the Treasury of the United States, a Federal Reserve Bank, or a Federal Home Loan Bank; a check drawn on a state or local government; or a check payable in a medium other than United States currency.

 (C) Both the electronic and paper items have been presented for payment. (RCK = R53; ARC, BOC, and POP =R37)

 (D) Amount was not accurately obtained from the source document. (RCK = R51; ARC and BOC = R10)

 (E) The notice stating the terms of the policy was not provided tome in advance of receiving the paper item to which the electronic entry relates.  (RCK = R51; ARC, BOC and POP = R10)

  (F) All signatures on the original item are not authentic or authorized.  (RCK only; use R51)

 (G) The original item has been altered.  (RCK only; use R51)

 (H) I opted out of check conversion activity. (ARC and BOC = R10)

I further depose and say that the debit transaction was not originated with fraudulent intent by me or by any person acting in concert with me, and that the signature below is my own proper signature. I certify under penalty of perjury that the foregoing is true and correct.


Date:  _______________  Signature:  __________________________________________________


Acknowledge by financial institution branch #______ Employee:__________________ Date:________