1. Payment Selection (Select One) (Module)
Authorization Type | Amount | Frequency/Rule | Start Date | End Date/Until Revoked | Max Cap (if variable) |
☐ One-time | $[Amount] | [N/A] | [Date] | [N/A] | [N/A] |
☐ Recurring | $[Amount] | [Weekly/Monthly/Other] | [Start Date] | [End Date/Until Revoked] | [N/A] |
☐ Variable | [As invoiced] | [Billing rule] | [Start Date] | [End Date/Until Revoked] | $[Maximum Amount] |
Authorization Type | Amount | Frequency/Rule | Start Date | End Date/Until Revoked | Max Cap (if variable) |
☐ One-time | $[Amount] | [N/A] | [Date] | [N/A] | [N/A] |
☐ Recurring | $[Amount] | [Weekly/Monthly/Other] | [Start Date] | [End Date/Until Revoked] | [N/A] |
☐ Variable | [As invoiced] | [Billing rule] | [Start Date] | [End Date/Until Revoked] | $[Maximum Amount] |
Authorization Type
Amount
Frequency/Rule
Start Date
End Date/Until Revoked
Max Cap (if variable)
☐ One-time
$[Amount]
[N/A]
[Date]
☐ Recurring
[Weekly/Monthly/Other]
[Start Date]
[End Date/Until Revoked]
☐ Variable
[As invoiced]
[Billing rule]
$[Maximum Amount]
2. Parties
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]
3. Authorization
I authorize [Company Name] to initiate ACH debit entries from my bank account and, if necessary, credit entries for error corrections.
Invoice/Account Reference: [Invoice #/Account ID].
Bank Name: [Bank Name]
Account Type: ☐ Checking ☐ Savings
Routing Number: [Routing Number]
Account Number: [Account Number]
5. Effective Dates
This authorization is effective beginning [Start Date] and will remain in effect until [End Date] or until revoked in writing with at least [X] business days’ notice.
6. 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].
7. Cancellation
This authorization may be cancelled by providing written notice to [Company Name] at least [X] business days before the next scheduled payment.
Notice Address: [Billing Email/Address].
8. Fee and Return Record (Internal)
Return Fee Charged (if any): $[Amount]
Return Event Reference ID: [Ref ID]
Return Date: [MM/DD/YYYY]
9. Signature
Customer/Payor: ___________________________ Date: _________
Name: [Full Legal Name]
Company Representative: ____________________ Date: _________
Name/Title: [Full Name, Title]
Authorization Type | Amount | Frequency/Rule | Start Date | End Date/Until Revoked | Max Cap (if variable) |
☐ One-time | $[Amount] | [N/A] | [Date] | [N/A] | [N/A] |
☐ Recurring | $[Amount] | [Weekly/Monthly/Other] | [Start Date] | [End Date/Until Revoked] | [N/A] |
☐ Variable | [As invoiced] | [Billing rule] | [Start Date] | [End Date/Until Revoked] | $[Maximum Amount] |