Huntington Bank Dispute Form – Fill Out and Use This PDF

HUNTINGTON BANK - ACH DISPUTE FORM

(WRITTEN STATEMENT OF UNAUTHORIZED DEBIT)

Case Number#__________________

Name (please print or type) __________________________________________Contact Phone #_____________________________________

Account Number __________________________Amount of Debit $______________ Date of Debit ______________20______

Party Debiting the Account __________________________________________________________________________

Party Debiting the Account __________________________________________________________________________

Statement



I (the undersigned) 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 that conclusion.

(Please select the option that best fits your reason for dispute)

I did not authorize the party listed above to debit my account. (R10; R05 if CCD/CTX to consumer account)

I revoked authorization I had given to the party to debit my account before the debit was initiated. (R07 if PPD, TEL, or WEB entry only)

My account was debited before the date I authorized (R10)

My account was debited for an amount different than I authorized. (R10)

My account was debited, but the corresponding payment was not made to the intended third-party payee. (R10)

My check was improperly processed electronically (Check one of the following) For ARC, POP, and BOC entries only

The debit was not properly authorized by the party listed above in accordance with the requirements of the ACH Rules. (R10)

The check was ineligible to be initiated as an ARC, POP, or BOC entry. (R10)

The amount of the ARC, POP or BOC entry was not accurately obtained from the check. (R10)

Both the check and ARC, POP, and BOC entry to which it relates have been presented for payment. (R37)

For RCK Entries Only

The check was ineligible to be initiated as an RCK entry. (R51)

Notice was not provided by the party listed above in accordance with the requirements of the ACH Rules. (R51)

Signatures on the check to which the RCK entry relates were not authentic or authorized, or the check was altered. (R51)

The amount of the RCK entry was not accurately obtained from the check. (R51)

Both the RCK entry and the check to which the RCK entry relates have been presented for payment. (R53)

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. I have read this statement in its entirety and attest that the information provided on this statement is true and correct.

Date_________________ Account Holder Signature______________________________________________________________

Return completed dispute form by: FAX: (877) 211-1631

Mail: Huntington National Bank, 7 Eason Oval, ATTN: EA4W26 Columbus, OH 43219

To be completed by Branch personnel:

Branch Name & Cost Center___________________________ Colleague Name and Phone #____________________________________________

Member FDIC, ®, and Huntington® are federally registered service marks of Huntington Bancshares Incorporated.

03-2015