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].
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] |
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] |
Scheduled Date
Amount
Type (One-time/Recurring/Variable)
Result
Reference 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]
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] |