Written Statement of Unauthorized Debit (ACH) Online Customer Response Form

Written Statement of Unauthorized Debit (ACH) form for Altabank, Division of Glacier Bank. Please complete and verify your information below before submitting. All information must be completed to submit.

Account/Transaction Information

Full Name (First, Last)

Business Name (Business Accounts Only)

Phone

Account Number

Click "Add another response" to include an additional account number.

Amount of Debit ($)

Date of Debit (MM/DD/YYYY)

Name of Party Debiting Your Account

Statement

I (the person named above) hereby attest that: (i) I have reviewed the circumstances of the above electronic (ACH) debit to my account; (ii) the debit was not authorized; and (iii) the following, to the best of my ability to identify, is the reason for the conclusion (select one):

I did not authorize the party listed above to debit my account.I revoked the authorization I had given to the party to debit my account before debit was initiated.My account was debited before the date I authorized.My account was debited for an amount different than I authorized.My check was improperly processed electronically.My account was debited, but the payment was never received by the intended recipient.Other

Date Authorization Was Revoked

If "Other" Please Specify

Signature

I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the debit above was not originated with fraudulent intent by me or any person acting in concert with me.

By checking “I agree” and submitting this form you state that you have read this statement in its entirety and attest that the information provided on this statement is true and correct.

I Agree

Note: This form is time dated when submitted. The date submitted must be on or after the date of the debit as indicated in the “Account/Transaction Information” you provided and confirmed above.

Contact Information