Unauthorized Electronic (ACH) Debit Lawrenceburg Federal Bank

Written Statement of Unauthorized Electronic (ACH) Debit

Institution Name and Address: Lawrenceburg Federal Bank PO Box 310 Lawrenceburg, TN 38464

Account Title & Address(Required)

Debited Account Number(Required)

Amount of Debit(Required)

Date of Debit(Required)

Payee (Party Debiting the Account)(Required)

Statements

I, the undersigned, hereby state all of the following: I am an authorized signer or otherwise have the authority to act on the debited account described above. I have reviewed the circumstances of the electronic debit to the account, as described above. I have concluded the debit was not authorized. The following, to the best of my knowledge, is the reason for that conclusion:

Select At Least One(Required)

Unauthorized Transaction. The party listed above was not given authorization to debit the account. (Return code R10, except for CCD or CTX entries*)

Authorization Revoked. Before the debit was initiated, the authorization that had previously been given to debit the account was revoked. (Return code RO7)

Unauthorized I ransaction. ¡ne account was debited betore the date authorized..

The amount authorized is: (Return code R10)

Transaction

Unauthorized Transaction. The account was debited for an amount different than authorized.

The amount authorized is: (Return code R10)

Transaction

Incomplete Transaction. The account was debited by an authorized third party, but that third party failed to make the payment as instructed. (Return code R10)

Improper Transaction. A check was improperly processed electronically. (Return code R10)

Other

If Other:

The debit was not originated with fraudulent intent by me or any person acting on concert with me.
(Note: Return code information is for internal use.)
*(Use return code R05 for consumer CCD or CTX entry, return code R29 for timely unauthorized non-consumer CCD or CTX entry, or return code R31 for permissible late unauthorized non-consumer CCD or CTX entry)

I have read the above statements in their entirety and certify that the statements and information provided are true and correct.(Required)

I understand this is a legal representation of my signature.

Date(Required)

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Unauthorized Electronic (ACH) Debit

Written Statement of Unauthorized Electronic (ACH) Debit

Statements