State of ____________________County of ____________________
I, _________________________________, state that I have examined the attached
statement or other notification from The Bancorp Bank, N.A. indicating that an ACH
debit entry was charged to my Account No. ____________________, on
________________, 20___ in the amount of $____________________, and that the
debit 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 that authorized by the consumer also is
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], Point-of-Purchase Entry [POP], or Accounts Receivable Entry
[ARC] that meets the criteria described in Section II below.
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I. For unauthorized entries, I further state that: (check one)
I did not
authorize, and have not ever authorized, _____________________(company name) to
originate one or more ACH entries to debit funds from any account at The Bancorp Bank, N.A..
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.
I authorized
_____________________ to originate one or more ACH entries to debit funds from
an account at The Bancorp Bank, N.A. but the amount debited is different than the amount I
authorized to be debited. The amount I authorized is $______________.
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__--_ .
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II. For improper entries, I further state
that: (check one)
* for RCK entries:
the item to which
the entry relates is ineligible to be initiated as an RCK entry;
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 NACHA
Operating Rules;
all signatures on
the item to which the RCK entry relates are not authentic or authorized, or the
item has been altered;
the amount of the
RCK entry was not accurately obtained from the item; or
both the RCK
entry and the item to which the RCK entry relates have been presented for
payment.
* for ARC entries:
notice was not
provided by the Originator in accordance with the requirements of the NACHA
Operating Rules;
the source
document used for the debit entry is improper;
both the source
document and the ARC entry to which it relates have been presented for payment;
or
the amount of the
ARC entry was not accurately obtained from the source document.
* for POP entries:
the debit entry
for which the Receiver is seeking recredit was not authorized by the Receiver;
the source
document used for the debit entry is improper; or
both the source
document and the POP entry to which it relates have been presented for payment.
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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 have read this statement in its entirety and attest that the information provided on this statement is true and correct.
Date ____________________
Signature____________________
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