required statement. - People`s United Bank

Written Statement of Unauthorized Debit
Instructions for Completing an Unauthorized Debit Transaction Claim Form
ATTENTION:
You must report all unauthorized debit transaction claims to the People’s United Bank
Call Center prior to submitting any forms to People’s United Bank
1-800-894-0300
1. Complete a separate claim form using the Written Statement of Unauthorized Debit for each company
originating transaction that you believe is not authorized.
2. For multiple transactions originating from the same company, you may list them on the back of the same
claim form or on the bottom of the form, and check the appropriate reason on the form for all.
3. Review your account transaction history to ensure that the transactions you are questioning were not
previously processed. The item may have been returned and your account credited.
4. Sign each claim form submitted.
5. Return the claim form(s) to the address below. If the claim form is not received via mail or email within
9 days from the date you first reported your disputed transaction, your claim may be closed.
Mail Claim Forms to:
People’s United Bank ACH Department
[RC 05-651]
850 Main St.
PO Box 7009
Bridgeport, CT 06604
Or email completed forms to [email protected]
ACH 03/2015
People’s United Bank, N.A. | Member FDIC
Written Statement of Unauthorized Debit
Customer Information
Name
Amount of Debit
Account Number
Date of Debit
Party Debiting the Account
Statement
I (the undersigned) hereby attest that (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:
I did not authorize the party listed above to debit my account. (R10; R05 if CCD/CTX to consumer account)
I revoked authorization I had given to the party to debit my account before the debit was initiated. (R07 for recurring PPD/WEB
entries only)
My account was debited before the date I authorized (R10)
My account was debited for an amount different than I authorized. (R10)
My check was improperly processed electronically (check one of the following below)
For ARC, POP and BOC Entries Only
I have opted to not have my check converted. (R10)
The debit was not properly authorized by the party listed above in accordance with the requirements of the ACH Rules(R10)
The check was ineligible to be initiated as an ARC, POP or BOC entry. (R10)
The amount of the ARC, POP or BOC entry was not accurately obtained from the check. (R10)
Both the check and ARC, POP or BOC entry to which it relates have been presented for payment. (R37)
For RCK Entries Only
The check was ineligible to be initiated as an RCK entry. (R51)
Notice was not provided by the party listed above in accordance with the requirements of the ACH Rules. (R51)
Signatures on the check to which the RCK entry relates were not authentic or authorized, or the check was altered. (R51)
The amount of the RCK entry was not accurately obtained from the check. (R51)
Both the RCK entry and the check to which the RCK entry relates have been presented for payment. (R53)
Customer Authorization
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 with fraudulent intent by me or any person acting in concert with me.
I have read this statement in its entirety and attest that the information provided on this statement is true and correct.
Account Holder Signature
Date
People's United Bank Internal Use Only
Date Received
Bank Rep Signature
ACH 03/2015
Bank Rep Name
Claim #
People’s United Bank, N.A. | Member FDIC