Building Picture EPB Employees Credit Union
1500 McCallie Avenue, Chattanooga, TN 37404 USA
Phone: (423) 648-3413, Fax: (423) 698-2912, email: epbecu@epbecu.org
ACH RETURN AUTHORIZATION FORM
Written Statement Under Penalty of Perjury
State of: _______________________________ County of: ______________________________

I, _________________________, depose and say that I have examined the attached statement or other notification from EPB Employees Credit Union indicating that an ACH debit entry was charged to my account #_______________ on ____________________, 20____ in the amount of $______________.____, and that the debit was unauthorized or improper.

An unauthorized debit (with the exception of TEL entries) means an electronic funds transfer from a consumer's account initiated by a person which was not authorized by the consumer, via a writing that was either signed or similarly authenticated, to initiate the transfer. With respect to TEL entries, an unauthorized debit means an electronic fund transfer from a consumer's account initiated by a person who was not authorized by the consumer, via an oral authorization, to initiate the transfer. An electronic fund transfer in the amount greater than that authorized by the consumer or which results in a debit to the consumer's account earlier than that authorized by the consumer also is an unauthorized debit. An unauthorized debit does not include an electronic fund transfer initiated with fraudulent intent by the consumer or any person acting inconcert with the consumer. An improper debit means a Prearranged Payment and Deposit Entry (PPD), Re-presented Check Entry (RCK), Point-of-Purchase Entry (POP), or Accounts Receivable Entry (ARC) that meets the criteria described in Section II below.

I. For unauthorized entries, I further depose and say that: (check one)

_________ I did not authorize, and have not ever authorized, in writing _______________________ (company name) to originate one or more ACH entries to debit funds from any account at EPB Employees Credit Union.

_________ I authorized _______________________ (company name) to originate one or more ACH entries to debit funds from my account, but on ___________________, 20____ I revoked that authorization by notifying ____________________ in the manner specified in the authorization.

_________ I authorized _______________________ (company name) to originate one or more ACH entries to debit funds from an account at EPB Employees Credit Union, but

OR ____________ the amount debited exceeds the amount I authorized to be debited. The amount I authorized is $______________._____.

____________ the debit was made to my account on a date earlier than the date on which I authorized the debit to occur. I authorized the debit to be made to my account on or no earlier than __________________, 20_____.

II. For improper entries, I further depose and say that: (check one)

FOR RCK ENTRIES:

_________ the item to which the entry relates is ineligible to be initiated as an RCK entry;

_________ the required notice stating the terms of the re-presented check entry policy was not provided by the Originator in accordance with the requirements of the NACHA Operating Rules;

_________ all signatures on the item to which the RCK entry relates are not authentic or authorized, or the item has been altered;

_________ the amount of the RCK entry was not accurately obtained from the item (effective March 15, 2002);

_________ both the RCK entry and the item to which the RCK entry relates have been presented for payment.

FOR ARC ENTRIES:

_________ notice was not provided by the Originator in accordance with the requirements of the NACHA Operating Rules;

_________ the source document used for the debit entry is improper;

_________ both the source document and the ARC entry to which it relates have been presented for payment; or

_________ the amount of the ARC entry was not accurately obtained from the source document.

FOR POP ENTRIES:

_________ the debit entry for which the Receiver is seeking re-credit was not authorized by the Receiver;

_________ the source document used for the debit entry is improper; or

_________ both the source document and the POP entry to which it relates have been presented for payment.

I further depose and say that the debit transaction was not originated with fraudulent intent by me or any person acting in concert wit me, and that the signature below is my own proper signature.

Member’s Signature: _____________________________________ Date: ___________________

Member, please sign and return this form to the Credit Union as soon as possible.