ACH Authorization Form Template

This ACH Authorization Form (“Form”) is executed on [Date] between:

Business/Payee: [Company Name]
Address: [Company Address]
Contact Information: [Phone, Email]

and

Customer/Payor: [Full Name]
Address: [Customer Address]
Phone: [Customer Phone]
Email: [Customer Email]

1. Authorization

I hereby authorize [Company Name] to initiate electronic debit entries from my bank account listed below, and if necessary, credit entries for error corrections. This authorization applies to:

• ☐ One-time payment of $[Amount]

• ☐ Recurring payments of $[Amount] on [Frequency, e.g., Monthly on the 1st]

• ☐ Variable payments as invoiced, not to exceed $[Maximum Amount]

2. Bank Account Information

• Bank Name: ____________________________

• Account Type: ☐ Checking ☐ Savings

• Routing Number: ________________________

• Account Number: ________________________

3. Effective Dates

This authorization is effective beginning [Start Date] and will remain in effect until:

• ☐ [End Date]

• ☐ Revoked in writing by the Payor with at least [X] business days’ notice.

4. Terms and Conditions

• I understand that payments may be rejected for insufficient funds or incorrect account details.

• I am responsible for any bank fees incurred due to failed transactions.

• I acknowledge that this authorization does not modify my obligations under any related contract or agreement with [Company Name].

5. Cancellation

This authorization may be cancelled by providing written notice to [Company Name] at least [X] business days before the next scheduled payment.

6. Signature

Customer/Payor: ___________________________ Date: _________
Name: [Full Legal Name]

Company Representative: ____________________ Date: _________
Name/Title: [Full Name, Title]