Written Statement of Unauthorized Draft

Written Statement of Unauthorized Draft

  • Account/Transaction Information

  • Date Format: MM slash DD slash YYYY
  • Statement

    I (the undersigned) hereby attest that (i) have reviewed the circumstances of the above draft to my account, (ii) the draft was not authorized, and (iii) the following, to the best of my ability to identify, is the reason for that conclusion:
  • I further state that the draft transaction was not originated with fraudulent intent by me or by any person acting in concert with me, and that the signature above is my own proper signature. I certify under penalty of perjury that I have read this statement in its entirety, that the information provided on this statement is true and correct, and that I am an authorized signer or have authority to act on the account.
  • Date Format: MM slash DD slash YYYY