Written Statement of Unauthorized Debit (ACH)

Member Number (Required)

Member Name

Daytime Telephone Number

Amount of Debit

Date of Debit

Company Debiting the Account

Must match the description exactly as shown on your statement.

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.

Amount and Date of Transaction #1

Amount and Date of Transaction #2

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 Name & ID)

Date

Rev: 03/08/2023

Form Instructions

Your Information