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ACH Authorization Form Template – California
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ACH Authorization Form Template
1. Business/Payee and Customer/Payor
This ACH Authorization Form ("Form") is executed on [Date] between:
Business/Payee: [Company Name]
Address: [Company Address]
Contact Information: [Phone, Email]
Customer/Payor: [Full Name]
Address: [Customer Address]
Phone: [Customer Phone]
Email: [Customer Email]
2. Authorization
I 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] on [Debit Date].
☐ Recurring payments of $[Amount] on [Frequency and Rule, e.g., Monthly on the 1st].
☐ Variable payments as invoiced, not to exceed $[Maximum Amount] per [Billing Period].
Invoice/Account Reference (if applicable): [Invoice #/Account ID].
3. Bank Account Information
Bank Name: [Bank Name]
Account Type: ☐ Checking ☐ Savings
Routing Number: [Routing Number]
Account Number: [Account Number]
4. Effective Dates and Duration
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.
5. 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].
6. Cancellation
This authorization may be cancelled by providing written notice to [Company Name] at least [X] business days before the next scheduled payment.
Cancellation Notice Delivery: [Email/Mail/Portal] to [Notice Address].
7. Debit Attempt Log (Internal Use)
Scheduled Date | Amount | Type (One-time/Recurring/Variable) | Result | Reference ID/Notes |
[MM/DD/YYYY] | $[Amount] | [Type] | [Processed/Returned/Pending] | [Ref ID/Notes] |
[MM/DD/YYYY] | $[Amount] | [Type] | [Processed/Returned/Pending] | [Ref ID/Notes] |
8. Change Request Marker
Bank Detail Change Requested On: [Date]
Change Effective Date: [Date]
Change Authorized By: [Name/Signature Method]
Change Reference ID: [Ref ID]
9. Signature
Customer/Payor: ___________________________ Date: _________
Name: [Full Legal Name]
Company Representative: ____________________ Date: _________
Name/Title: [Full Name, Title]
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Learn more about
ACH Authorization Form Template – California
Click below for detailed info on the template.
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.
California ACH Authorization Form Template FAQ
What does an ACH authorization actually allow a business to do?
An ACH authorization is the customer’s written permission for a business to initiate electronic entries to a specified bank account under the payment terms stated in the form. In most cases that means debit entries for payments and, if needed, credit entries to correct errors. The authorization should be specific about the payment type, amount, and timing so it is not open-ended. It does not replace the underlying contract for goods or services; it simply sets the payment mechanism. Keeping the authorization clear and signed helps reduce disputes about whether a particular withdrawal was approved.
How can I set up recurring ACH payments without losing control of the amount?
If you want recurring payments but do not want unlimited debits, include a defined amount and schedule or use a maximum cap per billing period. A cap works well when invoices vary but still need boundaries. You can also require an invoice reference or billing notice period as part of the authorization so the customer can match each debit to a specific charge. The goal is to make the authorization predictable and reviewable. Clear caps and references can also speed up internal billing because staff do not need to guess whether a higher-than-normal debit is permissible.
Why does the California version include a debit attempt log table?
A debit attempt log provides a simple internal record of each scheduled or attempted ACH entry, including the date, amount, and outcome. This is useful when there are failed entries, retries, or customer questions about timing. The table format also helps reconcile bank returns because you can match a return code event to a specific debit line item. Even if you do not share the log with the customer, having it in the file can reduce back-and-forth and support faster issue resolution. It is designed as a workflow tool, not a legal requirement statement.
What information is essential to avoid processing errors?
Processing errors most often come from incorrect routing numbers, transposed account digits, or unclear account type selection. The form should capture bank name, routing number, account number, and whether the account is checking or savings. It also helps to include the payer’s full name as it appears on the account and a preferred contact method in case a correction is needed. If the authorization is for variable amounts, the maximum cap should be stated clearly. A clean, complete set of bank details reduces returned payments and avoids delays caused by repeated clarification requests.
How should cancellation be handled in an ACH authorization form?
Cancellation should be handled with a clear notice method and a clear timing rule, such as written notice a certain number of business days before the next scheduled debit. The form should also identify where notice must be sent so there is no dispute about delivery. If the customer cancels late, you can state that a payment already in process may still be processed. The goal is predictability for both sides: the customer knows how to stop future debits, and the business can manage billing cycles without surprise. Keeping a cancellation record ID or timestamp can also be helpful for internal tracking.
Can an ACH authorization be used for one-time, recurring, and variable payments in the same form?
Yes, a single form can include multiple authorization types as long as the customer selects one and the relevant fields are completed. One-time authorizations should capture the amount and date. Recurring authorizations should capture the amount and frequency, plus start and end conditions. Variable authorizations should include an invoicing reference approach and a maximum cap so the customer can understand the boundaries. The key is to avoid leaving multiple options simultaneously selected. A clear selection method reduces confusion and helps prevent disputes about whether the payer intended a recurring authorization when they only wanted a one-time debit.
Can AI Lawyer help me tailor an ACH authorization to my billing workflow?
AI Lawyer can help you generate an ACH authorization that fits your billing cadence by adding structured fields for invoice references, maximum caps, notice periods, and internal processing steps. You can also format the template so it is easier to complete, with clear section order and a table block for tracking debits or cancellations. You still decide the commercial terms and how you communicate upcoming debits to customers, but a consistent template can reduce payment disputes and returned entries. A well-structured form also helps staff process authorizations consistently across different customer accounts.
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