Written Statement of Unauthorized Debit

Transaction Information


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.
For ARC, POP and BOC Entries Only For RCK Entries Only


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.

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