Bank of America

ATTN: ACH Disputes

AZ9-503-01-17
PO Box 53142
Phoenix, AZ 85072-3142
Fax: 1.877.292.7508

BANK OF AMERICA ACH

AFFIDAVIT OF UNAUTHORIZED ACH DEBIT ACTIVITY
(Written Statement Under Penalty Of Perjury)

CUSTOMER NAME
JUDY L MCCOY ACCT ENDING IN 6847

CLAIM # 1822707MAY10

NAME OF MERCHANT TRANSACTION AMOUNT POSTING DATE

                 

                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 

PLEASE CONTINUE TO NEXT PAGE

WSUPP:JHB-1207 Page 1 of 3
 BANK OF AMERICA ACH
AFFIDAVIT OF UNAUTHORIZED ACH DEBIT ACTIVITY
(Written Statement Under Penalty Of Perjury)

CUSTOMER NAME
JUDY L MCCOY ACCT ENDING IN 6847

CLAIM # 1822707MAY10

CUSTOMER MUST COMPLETE ALL PAGES AND COMPLETE THE SIGNATURE LINE ON THE LAST PAGE.

I state that I have examined the transaction information above, and I have completed the applicable section below to indicate the
transaction(s) error type.

COMPLETE ONLY ONE SECTION (A, B, C, OR D):

A. TRANSACTION(S) WAS AUTHORIZED, AND I HEREBY WITHDRAW MY CLAIM

After further review of the reported transaction(s), I have determined that it was authorized. I hereby withdraw my claim..

B. TRANSACTION(S) WAS UNAUTHORIZED (CHECK ONLY ONE ITEM)

I, or any other authorized signer on my account, or any other person authorized by me, did not initiate or authorize the
referenced ACH debit entry (ies) to my account at Bank of America.

I authorized an ACH debit entry(ies) to my account by the merchant(s) shown, but:

The amount(s) debited exceeds the amount(s) I authorized to be debited. The amount(s) I authorized was $__________.
The debit(s) was made to my account on a date earlier than the date on which I authorized the debit(s) to occur. I
authorized the debit(s) to be made to my account on (or no earlier than) _________________ (MM/DD/YY)

C. AUTHORIZATION REVOKED
I authorized the merchant to originate one or more ACH debit entry(ies) to my account, but on ____________ (MM/DD/YY) I
notified the merchant that I revoked my authorization.

WSUPP:JHB-0208 Page 2 of 3
 BANK OF AMERICA ACH
AFFIDAVIT OF UNAUTHORIZED ACH DEBIT ACTIVITY - Page 2
(Written Statement Under Penalty Of Perjury)

CUSTOMER NAME
JUDY L MCCOY ACCT ENDING IN 6847

CLAIM # 1822707MAY10

D. TRANSACTION(S) WAS IMPROPER (CHECK ONLY ONE ITEM)

An improper debit is a re-presented check (RCK), Point-of-Purchase (POP), Accounts Receivable (ARC), or Back-Office Conversion
(BOC) entry which meets the criteria described below.

Item ineligible – The item(s) to which the entry(ies) relates was ineligible to be initiated as an RCK entry.
Notice not provided – The merchant did not provide me with the required notice stating the terms of the [RCK][ARC] conversion.
Signature not authentic/item altered – All signatures on the item(s) to which the RCK entry(ies) relates are not authentic or
authorized, or the item(s) was altered.
Amount not accurately obtained – The amount of the [RCK][ARC] entry(ies) was not accurately obtained.
Duplicate entry – Both the original [RCK][ARC][POP] entry(ies) and the source document(s)/item(s) to which it relates have been
presented for payment, or a duplicate, unauthorized entry(ies) [PPD, TEL, WEB] was posted to my account.
Improper source document – The source document(s) used for the [ARC][POP] entry was improper.
Opted out – I advised the merchant that I did not want my check(s) converted to ACH debit entry(ies) [ARC][BOC].

WARNING!  If you completed more than one section (A, B, C, or D) above, this document may not be effective.

If the account referenced above is closed, please provide another Bank of America account number for any adjustments we may make to
process this claim. Alternate account number:

I further state that the ACH debit entry(ies) was not originated with fraudulent intent by me, by any other authorized signer on my
account, or by any person acting in concert with me, and that the signature below is my own proper signature.

I certify under penalty of perjury that this Affidavit is true and correct.

Date: _______________ Signature:

Please include all Affidavit pages and mail or fax to:

Bank of America FAX: 877.292.7508

ATTN: ACH Disputes
AZ9-503-01-17
PO Box 53142
Phoenix, AZ 85072-3142

WSUPP:JHB-0208 Page 3 of 3