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

Written Statement of Unauthorized Debit (ACH) form for Altabank, formerly Bank of American Fork, Lewiston State Bank, and People’s Town & Country Bank, divisions of People’s Intermountain Bank. Please complete and verify your information below before submitting. All information must be completed to submit.

Account/Transaction Information









Statement

I (the person name 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):



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.

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.