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ACH Authorization Form

Authorize secure electronic payments directly from bank accounts with this ACH Authorization Form Template.

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ACH Authorization Form

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]

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ACH Authorization Form

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For quick answers, scroll below to see the FAQ.

Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.

ACH AUTHORIZATION FORM FAQ


What is an ACH Authorization Form?

An ACH Authorization Form is a written document that allows a business, employer, or service provider to electronically withdraw funds from a customer’s or employee’s bank account through the Automated Clearing House (ACH) network.


Why is an ACH Authorization Form important?

It ensures legal compliance with banking regulations, protects both payer and payee, and provides a record of consent for recurring or one-time electronic transfers. It also reduces reliance on paper checks and speeds up transactions.


When should you use an ACH Authorization Form?

Use it whenever setting up recurring payments (such as rent, subscriptions, or loan repayments), payroll direct deposits, or any situation requiring bank-to-bank electronic transfers.


What should an ACH Authorization Form include?

It should include the payer’s name, bank account details, authorization for one-time or recurring payments, frequency of withdrawals, start/end dates, and a signature.


Is an ACH Authorization Form legally binding?

Yes. Once signed, it authorizes the business to initiate ACH transfers in compliance with federal banking rules and NACHA regulations. Both parties must retain a copy for record-keeping.


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