Written Statement of Unauthorized Debit

Transaction Information

Today's Date Account Number Name Date of Debit Party Debiting the Account Amount of Debit $

Statement

By submitting this Written Statement of Unauthorized Debit, I attest that (i) I have reviewed the circumstances of the above electronic (ACH) debit to my account, (ii) the debit was not authorized, and (iii) the following, to the best of my ability to identify, is the reason for that conclusion:

Please select the option that best fits your reason for dispute. I did not authorize the party listed above to debit my account. I revoked authorization I had given to the party to debit my account before the debit was initiated. My account was debited before the date I authorized. My account was debited for an amount different than I authorized. My account was debited, but the corresponding payment was not credited to my account with the party above. I authorized the party above to debit my account, but they exceeded the permissible attempts to collect. My account was debited by an improper reversal. My check was improperly processed electronically (Check one of the following):

For ARC, POP and BOC Entries Only The debit was not properly authorized by the party above in accordance with the ACH Rules requirements. The check was ineligible to be initiated as an ARC, POP or BOC entry. The amount of the ARC, POP or BOC entry was not accurately obtained from the check. Both the check and ARC, POP or BOC entry to which it relates have been presented for payment. For RCK Entries Only The check was ineligible to be initiated as an RCK entry. Notice was not provided by the party listed in accordance with the ACH Rules requirements. Signatures on the check were not authentic or authorized, or the check was altered. The amount of the RCK entry was not accurately obtained from the check. Both the RCK entry and the check to which the RCK entry relates have been presented for payment.

Endorsement

I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the debit above was not originated by me or any person acting in concert with me with fraudulent intent. l have read this statement in its entirety and attest that the information provided on this statement is true and correct.

Note to Account Holder: Your account will be promptly recredited unless otherwise notified by the Financial Institution. All credits are FINAL unless upon review by First Federal Savings Bank the transaction does not meet all of the qualifications listed above or is outside the return window. In this circumstance the customer will be provided with a revised form via email or mail indicating that the credit is provisional. Notification of provisional credit will be given prior to a credit posting to the account.

Account Holder Signature Date