Written Statement Under Penalty of Perjury
Effective March 15, 2003
State of _________________________ County of ___________________________
I, ______________________________ (consumer name), state that I have examined the attached statement or other notification from ________________________ (financial institution name) indicating that an ACH debit entry was charged to my account number ____________________ on _______________ (date) in the amount of $___________, and that the entry was unauthorized or improper.
An unauthorized debit (with the exception of TEL entries) means an electronic fund transfer from a consumer’s account initiated by a person who was not authorized by the consumer, via a writing that was either signed or similarly authenticated, to initiate the transfer. With respect to TEL entries, an unauthorized debit means an electronic fund transfer from a consumer’s account initiated by a person who was not authorized by the consumer, via an oral authorization, to initiate the transfer. An electronic fund transfer in an amount greater than that authorized by the consumer or that results in a debit to the consumer’s account earlier than authorized by the consumer is also an unauthorized debit. An unauthorized debit does not include an electronic fund transfer initiated with fraudulent intent by the consumer or any person acting in concert with the consumer. An improper debit means a Re-presented Check Entry (RCK), Accounts Receivable Entry (ARC), or Point-of-Purchase Entry (POP) that meets the criteria described below in Section II.
I. For unauthorized entries, I further state that: (check one)
 I did not authorize, and have not ever authorized, _____________________________________________. (R10) (company name) to originate one or more ACH entries to debit funds from any account at [Financial Institution].
 I authorized _____________________________________ (company name) to originate one or more ACH entries to debit funds from my account, but on _________________________, 20_____ I revoked that authorization by notifying _______________________________________ in the manner specified in the authorization. (R07)
 I authorized ________________________________________ (company name) to originate one or more ACH entries to debit funds from an account at [Financial Institution] but:
____ the amount debited exceeds the amount I authorized to be debited. The amount I authorized is $______________. (R10) OR
____ 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___. (R10)
II. For improper entries, I further state that: (check one)
For RCK Entries Only
 The item to which the entry relates is ineligible to be initiated as an RCK entry; (R51)
 The required notice stating the terms of the Re-presented Check Entry policy was not provided by the Originator in accordance with the requirements of the ACH Rules; (R51)
 All signatures on the item to which the RCK entry relates are not authentic or authorized, or the item has been altered; (R51)
 The amount of the RCK entry was not accurately obtained from the item (effective March 15, 2002); (R51) OR
 Both the RCK entry and the item to which the RCK entry relates have been presented for payment (effective March 15, 2002). (R53)
For ARC Entries Only (Effective March 15, 2002)
 Notice was not provided by the Originator in accordance with the requirements of the ACH Rules; (R10)
 The source document used for the debit entry is improper; (R10)
 Both the source document and the ARC entry to which it relates have been presented for payment; (R37) OR
 The amount of the ARC entry was not accurately obtained from the source document. (R10)
For POP Entries Only
 The debit entry for which the Receiver is seeking recredit was not authorized by the Receiver; (R10)
 The source document used for the debit entry is improper (effective March 15, 2002); (R10) OR
 Both the source document and the POP entry to which it relates have been presented for payment (effective March 15, 2002) (R37).
I further state that the 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.
Date & Place___________________________ Signature ______________________
I PULLED THIS FROM MY ARCHIVED FILES. PLEASE REVIEW TO ENSURE CURRENT/NEW TYPES ACH TRANSACTIONS ARE INCLUDED ON FORM.
ALSO, THE  ON THE FORM ARE ACTUALLY BOXES WHICH WOULD BE CHECKED BY INDIVIDUAL COMPLETING THE FORM.