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ACH Authorization Form Template – Texas
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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] — [Company Address] — [Phone, Email]
Customer/Payor: [Full Name] — [Customer Address] — [Customer Phone] — [Customer Email]
2. Authorization Type and Limits
I authorize [Company Name] to initiate ACH debit entries from my bank account and, if necessary, credit entries for error corrections.
Select one: ☐ One-time ☐ Recurring ☐ Variable.
One-time: $[Amount] on [Date].
Recurring: $[Amount] on [Frequency/Rule] starting [Start Date].
Variable: As invoiced, not to exceed $[Maximum Amount] per [Billing Period].
3. Bank Account Information
Bank Name: [Bank Name]
Account Type: ☐ Checking ☐ Savings
Routing Number: [Routing Number]
Account Number: [Account Number]
4. Effective Dates
This authorization is effective beginning [Start Date] and remains effective until [End Date] or until revoked in writing with at least [X] business days’ notice.
5. Terms and Conditions
Payments may be rejected for insufficient funds or incorrect account details.
Payor is responsible for bank fees incurred due to failed transactions.
This authorization does not modify obligations under any related contract with [Company Name].
6. Cancellation
Payor may cancel by providing written notice to [Company Name] at least [X] business days before the next scheduled debit.
Cancellation Notice Method and Address: [Email/Mail/Portal] to [Notice Address].
7. Corrective Actions Log (Internal Use)
Issue | Action | Owner | Due Date | Status | Reference ID |
[Return/Incorrect detail/Dispute] | [Call customer/Update details/Retry] | [Name/Team] | [MM/DD/YYYY] | [Open/Closed] | [Ref ID] |
[Return/Incorrect detail/Dispute] | [Call customer/Update details/Retry] | [Name/Team] | [MM/DD/YYYY] | [Open/Closed] | [Ref ID] |
8. Resubmission Marker
Resubmission Allowed: [Yes/No]
Resubmission Notice Method: [Email/Phone/Portal]
Resubmission 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 – Texas
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.
Texas ACH Authorization Form Template FAQ
Why is it helpful to separate authorization details from bank account details?
Separating the authorization terms from the bank account details makes the form easier to review and reduces errors. The authorization section should explain what will be debited, how often, and under what limits, while the bank section should capture the precise routing and account numbers. When these elements are mixed together, customers can miss key terms or staff can misread account information. A clean separation also helps with updates: if a customer changes bank accounts, the business can update the bank details without rewriting the authorization terms, assuming the payer confirms the change in writing. Clear structure is one of the simplest ways to reduce returned entries and disputes.
How should variable ACH payments be controlled to reduce disputes?
Variable payments work best when the authorization includes a maximum cap and a clear invoicing or notice reference. The payer should be able to match each debit to a specific invoice or statement, and the cap should prevent unexpected withdrawals. Some businesses also include a notice period placeholder, such as sending a billing notice a set number of days before the debit. The point is to create predictability even when amounts change. A variable authorization that lacks a cap or references tends to create confusion and can lead to higher dispute rates. Clear controls protect both the payer and the business.
Why does the Texas version include a corrective action log table?
A corrective action log helps track payment issues such as rejected entries, corrected account numbers, updated authorizations, and customer follow-ups. This is useful when an ACH debit fails and the business needs to document what was done to fix it before trying again. The table captures the issue, the owner, the due date, and the status, which makes handoffs easier between billing staff and customer support. It also provides a clear audit trail if a customer later asks why multiple attempts occurred. The log is an operational tool that helps keep the authorization process clean and consistent across multiple accounts.
What should a business do if a customer requests to change the bank account used for ACH?
When a customer changes the account, the safest approach is to capture the updated bank details in writing and confirm the effective date for the change. The form can include a change authorization method, such as requiring a new signature or an amendment line with a date. Internally, it helps to assign a reference ID to the updated authorization so staff can distinguish it from the old one. The goal is to prevent debits from being initiated against the wrong account and to ensure the customer cannot later claim the change was not authorized. Clear change documentation is often as important as the initial authorization.
Can a business initiate credit entries as well as debit entries under the authorization?
Many ACH authorizations include permission for credit entries to correct errors, such as reversing an incorrect debit or issuing a refund. Including that language can make error resolution smoother because the business can correct the transaction without requiring separate paperwork. The authorization should still focus primarily on debits and the payment terms, but a limited correction credit permission can be useful. The key is to keep the credit authority narrow and tied to corrections rather than open-ended transfers. Clear correction language can reduce friction when mistakes happen and can improve customer trust in the payment process.
How should disputes about an ACH debit be handled operationally?
Disputes are easier to manage when the business can show the signed authorization, the debit details, and the invoice or reference that supports the amount. Keeping a record of the notice sent, if any, and the customer’s account reference can also help. A good process is to request the specific debit date and amount being disputed and then respond with the matching documentation from the file. If a correction is warranted, document the corrective credit entry and update internal notes. The goal is a clear, repeatable workflow so disputes do not turn into informal back-and-forth without a documented outcome.
Can AI Lawyer help create an ACH form that supports a higher-volume billing team?
AI Lawyer can help you structure an ACH authorization so high-volume teams can process it consistently, including sections for invoice references, change tracking, and internal corrective action logging. You can also add clear placeholders for notice timing, debit caps, and customer communication channels so staff do not rely on ad hoc emails. The template does not replace your payment processor rules, but it can reduce administrative errors and improve recordkeeping. A consistent form often shortens onboarding time for new customers and makes it easier to resolve returns because the same fields are captured every time.
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