Written Statement of Unauthorized ACH Transaction

Name :

Member Number :

I, the undersigned, hereby attest I have reviewed by Noble Credit Union account statement or other notificaion indicating that an ACH debit posted to my account, and I attest that transaction(s) was unauthorized/revoked.

*A stop payment fee of $20 may be assessed for implementing this order.

ACH Transaction :

Was this an authorized transaction? Yes No

*I have contacted the company to stop this transaction from debiting my account? Yes No

*Company Name	*Amount	*Date Last Posted

Read and Acknowledge:

For pre-authorized entries, three business days advance notice prior to the expected transfer date of the debit entry is required to implement the stop payment request. If the stop payment order is received within three business days of the expected transfer date, we will attempt to satisfy the request of the account holder, but will not be held liable if sufficient time was not provided for a pre-authorized transfer that occurs within the three business day period. The account holder also understands that is necessary to provide the correct information related to the transaction(s) sufficient to enable the identification of the account the transaction(s) in question.

*Please click to continue

ACH Debit:

I (the undersigned) hereby attest I have reviewed the circumstances of the above electronic (ACH) debit posted to my account; the debt was:

Unauthorized
Pre-Authorized
Improper and the following selection, to the best of my ability, is the reason for that conclusion:

I did not authorize the company listed above to debit my account

I revoked the recurring payment authorization I had given to the party to debit my account before the debit was initiated. Date revoked :
This can include pre-authorized payment or deposit (PPD) , International ACH transactions (IAT) or recurring Internet-authorized entries (WEB)

The check was improperly processed electronically

Other (specify)

The amount debited was different than the amount I authorized to be debited for $

The debit was made earlier than the date on which I authorized the debit to occur on

Please check one: (must choose one)

I wish to revoke all future debits from this company.

I will continue to allow company to withdraw electronically.

Credit Union Use Only:

Driver Lic/ID# and Exp     Sig Card     Other

Accepted By:    Teller #    Date :

Processed By:    Teller #    Date :

Company ID:    Company Name:

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