WRITTEN STATEMENT UNDER PENALTY OF PERJURY FOR ACH ACTIVITY
Form should be faxed to (562) 596-9975, ATTN: ESD
State of:  County of: 
I, , depose and say that I have examined the attached statement or other notification from SCU indicating that an ACH debit entry was charged to my Account No. , on / / in the amount of $ , and that the debit was unauthorized or improper.

An unauthorized debit (with the exception of TEL entries) means an electronic fund 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 an amount greater than that authorized by the consumer or that 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 transfer initiated with fraudulent intent by the consumer or any person acting in concert with the consumer. An improper debit means a 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 state that: (check one)
I did not authorize, and have not ever authorized, (company name) to originate one or more ACH entries to debit funds from any account at SCU.
I authorized (company name) to originate one or more ACH entries to debit funds from my account, but on / / I revoked that authorization by notifying in the manner specified in the authorization.
I authorized to originate one or more ACH entries to debit funds from an account at SCU but
  The amount debited exceeds the amount I authorized to be debited. The amount I authorized is $ .
  OR
  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 / / .
II.  An improper entries, I further state that: (check one)
  * for Represented Check Entries:
  RCK01 -the item to which the entry relates is ineligible to be initiated as an RCK entry;
  RCK02 - the required notice stating the terms of the re-presented check entry policy was not provided by the Originator in accordance with the requirement of the NACHA Operating Rules.
  RCK03 - all signatures on the item to which the RCK entry relates are not authentic or authorized, or the item has been altered;
  RCK04 - the amount of the RCK entry was not accurately obtained from the item; or
  RCK05 - both the RCK entry and the item to which the RCK entry relates have been presented from payments.
  * for Account Receivable Entries:
  ARC01 - notice was not provided by the Originator in accordance with the requirement of the NACHA Operating Rules
  ARC02 - the source document used for the debit entry is improper;
  ARC03 - both the source document and the ARC entry to which it relates have been presented for payment; or
  ARC04 - the amount of the ARC entry was not accurately obtained from the source document.
  * for Point of Purchase Entries:
  The Receiver did not authorize the debit entry for which the Receiver is seeking recredit;
  POP01 - the source document used for the debit entry is improper; or
  POP02 - both the source document and the POP entry to which it relates have been presented for payment.
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 signature.

I certify under penalty of perjury that the foregoing is true and correct.
A $25.00 fee may be assessed.
Dated:                        _____                                   ____                                              
Signature