Ach Authorization Form
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1ACH Authorization form
Choose Your Option Below:
Recurring Billing
In consideration of the goods, products and/or services provided to me by
, as
listed below. I hereby authorize
to initiate a debit entry to my checking account
indicated below at the depository financial institution named below, hereinafter called Client Bank, and to debit the
same to such account for the amount listed below. This authorization will continue until revoked in writing.
Single Billing
In consideration of the goods, products and/or services provided to me by
as listed
below, I hereby authorize
to initiate a debit entry to my checking account indicated
below at the depository financial institution named below, hereinafter called Client Bank, and to debit the same to
such account for the amount listed below. This authorization will continue until revoked in writing.
Bank Information
Client Information
Client Bank Name:
Name:
Account Holder’s Name:
Address:
Bank Account Number:
City, State Zip:
Bank Routing Number (9 digits):
Phone:
I hereby assert that I am either the rightful and legal owner or I am a duly
Billing Amount
authorized signer on the account with the power to authorize these transactions
Amount:__________________________________
Print Name:
Signature:
Date:
By signing this agreement, I hereby authorize _____________________ to electronically debit the checking or savings account indicated above for
payments due under this agreement. I understand that the effective date of these electric debits to my account will be the business day on which the
payment is due or scheduled per this agreement. I understand that if the debit is returned unpaid due to insufficient funds or my banks electronic draft
restrictions, I may be charged a $25.00 NSF Penalty for the returned item.
Please Provide a Voided Check for Business. (Deposit Slip will not work)
If not, Have a letter from Bank verifying the Businesses Routing and Account Number on a bank letter head.
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Parent category: Business