Written Statement of Unauthorized Debit (WSUD)

(For Unauthorized/Improper ACH Debit)

Please complete the form below:

*Indicates a required field.
 

Account Number *
Social Security Number [9-18] *
Email Address Please provide a valid email address if you would like an autoresponder confirmation of retrieval message.
I, (Receiver's Name)* , depose and say that I have examined the attached statement or other notification from Financial Assurance Federal Credit Union indicating that an unauthorized or improper ACH debit entry was charged to my Account #* on (Date)* in the amount of $*
, and that the entry was unauthorized, improper, or a prior authorization was revoked. For secondary account holders, I further assert that I am an authorized signer or have authority to act on the above-referenced account.
Definitions
An unauthorized debit means an electronic fund transfer from a consumer’s account initiated by a person, which was not authorized by the consumer in writing to initiate the transfer. An electronic funds transfer in an amount greater than that authorized by the consumer or which results in a debit to the consumer’s account earlier than that 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 an (PPD)(RCK) entry for which (1) notice stating the terms of the re-presented check entry policy was not provided by the Originator, (2) the item to which the entry relates is not an eligible item, (3) all signatures on the item to which the entry relates are not authentic or authorized, or (4) the item to which the entry relates has been altered.
SECTION 1. UNAUTHORIZED ENTRIES (Complete this section for unauthorized entries only. For improper entries, please advance to SECTION 2.)
Date of Unauthorized Transaction
Company Name
Company Address
City		State- - Choose One - - AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip
For unauthorized entries, I further depose and say that: A) I authorized this company to originate one or more electronic entries to debit funds from my account but on a specific date I revoked that authorization by notifying the company. B) I did not authorize and have not ever authorized, in writing this company to originate one or more electronic entries to debit funds from any account at Financial Assurance Federal Credit Union. C) I authorized this company to originate one or more electronice entries to debit funds from my account, but the company did something different from what I authorized. (Please complete next section if selected)
If you selected (C) please complete this section: What was the error that the Company made with the transaction? (PLEASE SELECT ONE ONLY)
Error Type:
(I) Amount Error		The amount debited was different from the amount I authorized to be debited. The amount I authorized is  $
(II) Variable Amount Different		In the case of variable amounts, the amount debited was different from the amount on the required notice.  The authorized amount on the required notice was $
(III) Processed Early		The debit was made to my account on a date earlier than the date I authorized to be debited. I authorized the debit to be made to my account on or no earlier than  (date or day of the month)
END SECTION 1
SECTION 2. IMPROPER ENTRIES
For Improper Entries, further depose and say that: (PLEASE SELECT ONE) A) The notice stating the terms of the re-presented check entry policy was not provided to me in advance of receiving the item to which the re-presented check entry relates. B) All signatures on the item to which the re-presented check entry relates are not authentic or authorized. C) The item to which the re-presented check entry relates has been altered. D) The item was ineligible because either:
For (D) Please select one		the item to which the re-presented check entry relates is not an item within the meaning of Revised Article 4 of the Uniform (Commercial Code 1990 Official Text). the item to which the re-presented check entry relates is not a negotiable demand draft drawn on or payable through or at a Participating DFI, other than a Federal Reserve Bank or Federal Home Loan Bank. the item to which the re-presented check entry relates is in an amount of $2,500 or more. the item to which the re-presented check entry related does not indicate on the face of the document that the item was returned due to “Not Sufficient Funds”, “NSF”, “Uncollected Funds” or comparable language. the item to which the re-presented check entry relates is dated more than 180 days from the date the entry is transmitted to the RDFI. the item to which the re-presented check entry relates is drawn on a non-consumer account. the item to which the re-presented check entry relates has been previously presented (a) more than twice in paper form (for initial RCK entries) or (b) more than once in paper form and more than once as a re-presented check entry.
ELECTRONIC FORM SUBMISSION AGREEMENT: By submitting this form I am verifying the following: 1. The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the transaction requested above. 2. I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union. 3. I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval. 4. By entering my first and last name next to the Electronic Signature field, this stands as the equivalent of a handwritten signature. Therefore, the same laws and regulations regarding forgery apply. * I further depose and say that the debit transaction was not originated with fraudulent intent by me or any person acting in concert with me. In agreeance with the Electronic guidelines above, the signature below is my own proper signature.
Electronic Signature (Print First & Last Name) *
Date *
Please enter the characters in the image for enhanced security (SSL) *