This ACH Authorization Form (“Form”) is executed on [Date] between [Company Name] and [Full Name].
Preferred Notice Channel: [Email/Portal/Phone/Mail].
Notice Contact: [Email/Portal ID/Phone].
2. Parties
Business/Payee: [Company Name] — [Company Address] — [Phone, Email]
Customer/Payor: [Full Name] — [Customer Address] — [Customer Phone] — [Customer Email]
Customer/Account Reference: [Account ID/Invoice Prefix]
3. Authorization
I authorize [Company Name] to initiate ACH debit entries from my bank account listed below and, if necessary, credit entries for error corrections.
Authorization Type: ☐ One-time ☐ Recurring ☐ Variable (select one).
Bank Name: [Bank Name]
Account Type: ☐ Checking ☐ Savings
Routing Number: [Routing Number]
Account Number: [Account Number]
5. Effective Dates
Effective Start Date: [Start Date].
End Condition: [End Date/Until Revoked with 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 debit.
Cancellation Notice Address: [Billing Email/Address/Portal].
8. Transaction Profile (Variable Billing Controls)
Profile Item | Value | Reference Field | Notes |
Invoicing Trigger | [Monthly statement/Invoice/Usage] | [Invoice #/Statement ID] | [__] |
Maximum Cap | $[Maximum Amount] per [Billing Period] | [Cap Ref] | [__] |
Expected Frequency | [Weekly/Monthly/Other] | [Frequency Ref] | [__] |
Correction Credits | [Allowed for error correction] | [Correction Ref ID] | [__] |
Profile Item | Value | Reference Field | Notes |
Invoicing Trigger | [Monthly statement/Invoice/Usage] | [Invoice #/Statement ID] | [__] |
Maximum Cap | $[Maximum Amount] per [Billing Period] | [Cap Ref] | [__] |
Expected Frequency | [Weekly/Monthly/Other] | [Frequency Ref] | [__] |
Correction Credits | [Allowed for error correction] | [Correction Ref ID] | [__] |
Profile Item
Value
Reference Field
Notes
Invoicing Trigger
[Monthly statement/Invoice/Usage]
[Invoice #/Statement ID]
[__]
Maximum Cap
$[Maximum Amount] per [Billing Period]
[Cap Ref]
Expected Frequency
[Weekly/Monthly/Other]
[Frequency Ref]
Correction Credits
[Allowed for error correction]
[Correction Ref ID]
9. Internal Approval (Internal Use)
Approved By: [Name/Team] Approval Date: [MM/DD/YYYY]
Authorization Reference ID: [Ref ID]
10. Signature
Customer/Payor: ___________________________ Date: _________
Name: [Full Legal Name]
Company Representative: ____________________ Date: _________
Name/Title: [Full Name, Title]
Profile Item | Value | Reference Field | Notes |
Invoicing Trigger | [Monthly statement/Invoice/Usage] | [Invoice #/Statement ID] | [__] |
Maximum Cap | $[Maximum Amount] per [Billing Period] | [Cap Ref] | [__] |
Expected Frequency | [Weekly/Monthly/Other] | [Frequency Ref] | [__] |
Correction Credits | [Allowed for error correction] | [Correction Ref ID] | [__] |