ACH
STOP PAYMENT AND WRITTEN STATEMENT UNDER PENALTY OF PERJURY FOR
UNAUTHORIZED/IMPROPER ACH ENTRIES
Instructions:Do not use this
form for Bill Pay, Debit Card, or Credit Card transactions.
Call Member Phone Services at (866) 543-5202 or (408) 543-5202.
Complete this form online, print it out, sign it, and mail both
pages to Star One Credit Union, P.O. Box 3643, Sunnyvale, CA
94088-3643, or fax to (408) 543-5203 Attn: Statement/Support
Dept.
Prefer not to sign and mail? Log in to Online Banking
and click on the "Online Forms" icon to access our
secure form. It does not require your signature.
Date of Request:
Member Number:
Checking
Savings
Name:
Daytime Phone:
For Stop Payment. I state that: (select one)
This ACH Debit of $
is one specific item and a one-time Stop-Payment to
(company name); all such future payments are to be
paid.
This ACH Debit of $
is to be stopped for all future payments; I have or
will notify
(company name) about this continuing ACH Stop, and
I understand that this is valid for six months from
the date of this request, unless it is previously
canceled or renewed in writing by me.
For
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 on
/
/20
in the amount of $
, and I state that the ACH Debit was unauthorized. Reasons for Unauthorized Entries: (Select one)
I did not authorize
(merchant/company) to originate one or more ACH entries to
debit funds from my account at the Credit Union.
I did authorize
(merchant/company) to originate one or more ACH entries to
debit funds from my account, but on
/
/20
. I revoked that authorization by notifying
(merchant/company) in the manner specified in the authorization.
I did authorize
(merchant/company) to originate one or more ACH entries to debit
funds from my account at the Credit Union but, (check one)
the amount debited
exceeds the amount I authorized to be debited. The amount I
authorized is $
.
the debit was
made to my account on a date earlier than the date on which
I authorized the debit to occur. I authorized the debit to be
made to my account on or no earlier than
/
/20
.
For Improper Entries (Electronic Checks), I further state
that: (check one)
After
examining my statement or other notification from the credit
union, an ACH debit entry was charged to my account number listed
above on
/
/20
in the amount of $
, check number
, and I state that the ACH debit was improper.
Reasons for
Improper Entries: (Select One)
The check or
source document that I issued to
(merchant/company) for payment of goods and/or services was
debited improperly from my account.
The converted
electronic check and the original check that I issued to
(merchant/company) for payment of good and/or services, were
both debited against my account.
The required notice,
stating the terms that the check I originally issued may be
or will be converted electronically for payment, was not provided
to me.
The amount of
the converted electronic check is different from the amount
on the original check.
All signatures
on the item to which the electronic check relates are not authentic
or authorized, or the item has been altered.
I understand that a Stop Payment must be received
by the Credit Union at least (3) three business days before the
scheduled date of transfer in order to be effective. The Credit
Union may accept a stop payment order after that time, but will
not bear any liability if it does not act on the order. I authorize
a fee of $13.00 to be charge to the account referenced above for
a one-time Stop-Payment.
I further state that the ACH debit transaction
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 certify under penalty of perjury that the
foregoing is true and correct.
Member Signature: _____________________________________________
Date: ________________
