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Description: This section is used to return prior posted ACH transactions only. This section can also be used to place a Stop Payment on all future transactions at the same time. Multiple debits from the same debiting company may be listed on one form. The company must match exactly for multiple items to be returned from the same form. This form must be signed and dated ON or AFTER the item in question posts to the Customers account. Items will not be returned until a signed form is received. Return Prior Posted Transactions Stop All Future Transactions (Please contact the Originating Company to revoke authorization immediately. Bank may require written proof.) 1. Account and Transaction Information Name: Account Number: Amount(s) and Date(s)of Debit(s): Company Name Debiting the Account(as shown on Statement):

Description: This document serves as a written statement under penalty of perjury for an improper/unauthorized debit. It includes RCK, ARC, BOC and POP entries.

Description: This is the ACH Written Statement of Unauthorized Debit form, to be used when a consumer reports a problem with an ACH transaction. This form contains a unique area to address those areas when a customer has a recurring trasaction and has revoked their authorization prior to the next presentment.