WRITTEN STATEMENT UNDER PENALTY OF PERJURY
An Affidavit of Unauthorized/Improper Entry

    
    State of ________________________                           County of ___________________________    
    I, ____________________________ state that I have examined my statement (or other notification) from ________________________________ (financial institution's name) indicating that an ACH debit entry was charged to my account ______________________ (account number) on  ___________________ (MM/DD/YY), in the amount of $_________________, and that the entry was unauthorized or improper.    
    Section I.  I further state that: (check one)    
    □ Unauthorized - (R10)    
        I did not authorize ____________________________________ (the Company name) to originate the specified debit entry to my account at this financial institution.    
    □ I Authorized but -    
        I authorized ____________________________________ (the Company name) to originate the specified debit entry to my account at this financial   institution, but:    
           □ (R10) The amount debited exceeds the amount I authorized. The amount I authorized is  $___________, or;    
           □ (R10) The debit was made to my account on a date earlier than the date on which I authorized the debit to occur. I authorized the debit to be made to my account on (or no earlier than)  _____________ (MM/DD/YY).    
    □ Authorization Revoked - (R07)    
       I authorized __________________________________ (the Company name) to originate the specified entry to my account, but on __________________ (MM/DD/YY) I revoked that authorization by notifying the Company in the manner specified in the authorization.    
         
    Section II. I further state that: (check one)    
    □ The debit was improper due to the following reason -    
            □ (R10, R51) I was not provided the required notice. [RCK]  [ARC]  [POP] & [BOC]    
            □ (R10, R51) The signatures on the item are not authentic or authorized, and/or the item has been altered. [RCK]  [ARC]  [POP] & [BOC]    
            □ (R10, R51) The amount of the entry is different from the amount of the check. [RCK]  [ARC]  [POP] & [BOC]    
            □ (R10, R51) The item is ineligible to be initiated as an ACH entry. [RCK]  [ARC]  [POP] & [BOC]    
            □ (R05) Incorrect Standard  Entry Class (SEC) Code was used. (For Consumer Accounts only) [CCD vs. PPD]    
            □ (R37, R53) Both the check and the ACH entry posted to my account. [ARC]  [POP]  [RCK] & [BOC]    
    Section III. (For Corporate Accounts Only)    
    □ Corporate advises unauthorized (24 hours return time frame) - (R29)    
       I did not authorize _______________________________ (the Company name) to originate the specified debit entry to my account at this financial institution.    
         
    I further state that the debit transaction was not originated with fraudulent intent by me 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 the foregoing is true and correct.    
                        Date:______________________   Signature:_____________________________________________    
    Rev. 1/25/07    

Northern Paper Mills Credit Union
   

900 N. Jackson Street, Green Bay, WI 54302  Phone: 920-432-9044