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].
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] |
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] |
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]
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]
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] |