1. Authorization and Consent
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 the bank account in Section 3 and, if necessary, credit entries for error corrections.
Authorization Type Selected: ☐ One-time ☐ Recurring ☐ Variable (select one).
Business/Payee: [Company Name] — [Company Address] — [Phone, Email]
Customer/Payor: [Full Name] — [Customer Address] — [Customer Phone] — [Customer Email]
Customer/Account Reference: [Customer ID/Account #/Invoice Prefix]
Bank Name: [Bank Name]
Account Type: ☐ Checking ☐ Savings
Routing Number: [Routing Number]
Account Number: [Account Number]
4. Payment Parameters
One-time Amount and Date (if selected): $[Amount] on [Date].
Recurring Amount and Frequency (if selected): $[Amount] on [Frequency/Rule].
Variable Payment Cap (if selected): Not to exceed $[Maximum Amount] per [Billing Period].
Invoice Reference Method (if applicable): [Invoice #/Statement ID].
5. Terms, Returns, and Fees
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.
This authorization does not modify obligations under any related contract with [Company Name].
6. Cancellation and Revocation
This authorization may be cancelled by written notice to [Company Name] at least [X] business days before the next scheduled debit.
Notice Address: [Billing Email/Address].
7. Billing Calendar (Internal or Shared)
Billing Period | Invoice Date | Debit Date | Authorized Amount/Cap | Reference ID |
[MM/DD–MM/DD] | [MM/DD/YYYY] | [MM/DD/YYYY] | $[Amount or Cap] | [Invoice/Ref ID] |
[MM/DD–MM/DD] | [MM/DD/YYYY] | [MM/DD/YYYY] | $[Amount or Cap] | [Invoice/Ref ID] |
Billing Period | Invoice Date | Debit Date | Authorized Amount/Cap | Reference ID |
[MM/DD–MM/DD] | [MM/DD/YYYY] | [MM/DD/YYYY] | $[Amount or Cap] | [Invoice/Ref ID] |
[MM/DD–MM/DD] | [MM/DD/YYYY] | [MM/DD/YYYY] | $[Amount or Cap] | [Invoice/Ref ID] |
Billing Period
Invoice Date
Debit Date
Authorized Amount/Cap
Reference ID
[MM/DD–MM/DD]
[MM/DD/YYYY]
$[Amount or Cap]
[Invoice/Ref ID]
8. Signature Record
Signature Method: [Ink/E-Sign/Portal Approval]
Signature Audit/Transaction ID (if any): [ID]
9. Signature
Customer/Payor: ___________________________ Date: _________
Name: [Full Legal Name]
Company Representative: ____________________ Date: _________
Name/Title: [Full Name, Title]
Billing Period | Invoice Date | Debit Date | Authorized Amount/Cap | Reference ID |
[MM/DD–MM/DD] | [MM/DD/YYYY] | [MM/DD/YYYY] | $[Amount or Cap] | [Invoice/Ref ID] |
[MM/DD–MM/DD] | [MM/DD/YYYY] | [MM/DD/YYYY] | $[Amount or Cap] | [Invoice/Ref ID] |