AFFIDAVIT OF UNAUTHORIZED ACH

Member Services
PO Box 417
San Francisco, CA 94104

WRITTEN STATEMENT OF UNAUTHORIZED DEBIT (ACH)

I, , state that I have examined my statement or other notification from The Bancorp Bank indicating
that an ACH debit transaction was charged to my account as described below and that the debit was unauthorized.

TRANSACTION INFORMATION — (PLEASE PRINT)

Name:

Account Number: Date of Transaction: Amount of Transaction:

(mm/dd/yyyy)

Merchant or Business Name on the Transaction:

INSTRUCTIONS: PLEASE COMPLETE PART 1 TO INDICATE THE REASON FOR THIS

WRITTEN STATEMENT. PLEASE READ AND SIGN PART 2 OF THIS WRITTEN STATEMENT.
PART 1: UNAUTHORIZED TRANSACTION – PLEASE CHECK BELOW TO INDICATE THE
TRANSACTION WAS UNAUTHORIZED.
I did not authorize the merchant or business named above to debit funds from my account.

PART 2: SIGNATURE – REQUIRED

I am the account owner of, or otherwise have authority to act on, the account identified in this Written Statement. 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.
Signature:

Print Name: Daytime Phone Number: Date:

(mm/dd/yyyy)

Please email, mail or fax this completed, signed form and any additional information requested to:
Member Services
PO Box 417
San Francisco, CA 94104-0417
Fax: 415.449.3446
Email: claims@chimebank.com

Banking Services provided by The Bancorp Bank, Member FDIC.