Written Statement of Unauthorized Debit (ACH)

Please use the Written Statement of Unauthorized Debit (WSUD) to report an unauthorized direct debit entry made to an Interactive Brokers LLC brokerage account. Even if the unauthorized entry was previously reported to us orally or through a different written means, the WSUD must be submitted to us as a necessary part of reporting an unauthorized direct debit transaction. Failure to submit the WSUD to us within 10 business days may result in termination of our Direct Debit service.

The completed and signed WSUD may be sent to us (1) by uploading it to Account Management or (2) by mailing it to Interactive Brokers Direct Debit, 209 S. LaSalle Street, 10th Floor, Chicago, IL 60604. If you have any questions, please call 1-866-532-4654.

1. Account/Transaction Information

Account Owner: ______________________________________________________________

Account Number: ______________________________________________________

Person, Financial Institution or Company ("Debiting Party") Debiting the Account: __________________________________________________

Amount of Debit: ________________________________

Date of Debit: __________________________________

 

2. Account Owner's Statement

I, the undersigned, hereby attest that (I) I have reviewed the circumstances of the above electronic (ACH) direct 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: (please select one from the below)

_____ I did not authorize the Debiting Party listed above to debit my account

_____ I authorized the Debiting Party to debit funds from my account, however:

_____ the amount debited is more than the amount I authorized; OR

_____ the debit was made to my account on a date earlier than the date I authorized.

_____ I revoked the authorization I had given to the Debiting Party to debit my account before the debit was initiated. Date authorization was revoked __________________

_____ Other (must specify) _______________________________________________________

 

3. Signature

By signing below, I also verify that I am an authorized signer, or otherwise have the authority to act on the account identified, above, in this statement.

I attest that the debit, information for which is provided above, was not originated with fraudulent intent by me, any person acting on my behalf, 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.

 

Client name (print): ________________________________________

Client signature: __________________________________________

Date: _____________________________