Statement of Unauthorized Electronic Fund Transfer (EFT) Activity - $25.00

Table of Contents

Form Instructions
Section 1 - Customer Information
Section 2 - ATM, Point of Sale, Debit or Payroll Card Was Involved
Section 3 - Unauthorized Debit Entry Only
Section 4 - Improper Debit Entry Only
Section 5 - Stop Payment of Future Transactions
Section 6 - Authorization and Acknowledgement Statement
Notary Information
Bank Use Only

The purpose of this form is to be used by financial institution personnel to provide a form to customers for completion in the event they report unauthorized electronic fund transfer (EFT) account activity.  This form template (approximately 3 pages) is available to purchase from in Microsoft® Word format for $25.00

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