1. Authorization
This ACH Authorization Form (“Form”) is executed on [Date] between [Company Name] and [Full Name].
I authorize [Company Name] to initiate ACH debit entries from my bank account and, if necessary, credit entries for error corrections.
Authorization Type: ☐ One-time ☐ Recurring ☐ Variable (select one).
2. Customer/Payor Details
Customer/Payor: [Full Name]
Address: [Customer Address]
Phone: [Customer Phone]
Email: [Customer Email]
Customer/Account Reference: [Account ID/Invoice #]
3. Business/Payee Details
Business/Payee: [Company Name]
Address: [Company Address]
Contact: [Phone, Email]
Bank Name: [Bank Name]
Account Type: ☐ Checking ☐ Savings
Routing Number: [Routing Number]
Account Number: [Account Number]
5. Payment Parameters
One-time: $[Amount] on [Date].
Recurring: $[Amount] on [Frequency/Rule] starting [Start Date].
Variable: As invoiced, not to exceed $[Maximum Amount] per [Billing Period].
Effective Start Date: [Start Date]. End Condition: [End Date/Until Revoked].
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
Payor may cancel by providing written notice to [Company Name] at least [X] business days before the next scheduled debit.
Notice Address: [Billing Email/Address].
8. Return and Resolution Tracker (Internal Use)
Return Date | Debit Amount | Reason (if known) | Follow-Up Action | Outcome | Reference ID |
[MM/DD/YYYY] | $[Amount] | [NSF/Bad Account/Other] | [Action] | [Resolved/Pending] | [Ref ID] |
[MM/DD/YYYY] | $[Amount] | [NSF/Bad Account/Other] | [Action] | [Resolved/Pending] | [Ref ID] |
Return Date | Debit Amount | Reason (if known) | Follow-Up Action | Outcome | Reference ID |
[MM/DD/YYYY] | $[Amount] | [NSF/Bad Account/Other] | [Action] | [Resolved/Pending] | [Ref ID] |
[MM/DD/YYYY] | $[Amount] | [NSF/Bad Account/Other] | [Action] | [Resolved/Pending] | [Ref ID] |
Return Date
Debit Amount
Reason (if known)
Follow-Up Action
Outcome
Reference ID
[MM/DD/YYYY]
$[Amount]
[NSF/Bad Account/Other]
[Action]
[Resolved/Pending]
[Ref ID]
9. Internal Review Block
Received By: [Name/Team] Received On: [MM/DD/YYYY]
Verified Bank Fields: [Yes/No] Verification Reference ID: [Ref ID]
10. Signature
Customer/Payor: ___________________________ Date: _________
Name: [Full Legal Name]
Company Representative: ____________________ Date: _________
Name/Title: [Full Name, Title]
Return Date | Debit Amount | Reason (if known) | Follow-Up Action | Outcome | Reference ID |
[MM/DD/YYYY] | $[Amount] | [NSF/Bad Account/Other] | [Action] | [Resolved/Pending] | [Ref ID] |
[MM/DD/YYYY] | $[Amount] | [NSF/Bad Account/Other] | [Action] | [Resolved/Pending] | [Ref ID] |