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ACH Authorization Form Template – Washington
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ACH Authorization Form Template
1. Contact and Notice Preferences
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).
4. Bank Account Information
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] | [__] |
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]
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ACH Authorization Form Template – Washington
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For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Washington ACH Authorization Form Template FAQ
Why is it important to include a notice preference in an ACH authorization?
Notice preferences can make recurring or variable billing smoother because the payer knows where to look for reminders, invoices, or correction notices. While the authorization controls permission to debit, notice fields can reduce surprise and prevent missed communications if a payer uses a specific email or prefers portal messages. A notice preference also helps internal teams route time-sensitive issues like returned payments to the right channel quickly. The key is to keep notice preferences separate from the cancellation method, so the payer understands that cancellation still requires the stated written notice process. Clear communications reduce disputes and help payments run on schedule.
How does a transaction profile table help with variable ACH billing?
A transaction profile table provides a structured snapshot of how variable debits will work, such as the invoicing trigger, maximum cap, expected frequency range, and reference field used to match each debit to an invoice. This can reduce disputes because the payer can see the boundaries and the method for identifying each debit. Internally, the table helps billing teams apply the authorization consistently across accounts. It also creates an audit-friendly record when debits vary from month to month. The goal is predictability: even if amounts change, the process and limits are clear and documented in a consistent format.
What should the form say about correction credits and refunds?
If the business wants the ability to correct mistakes quickly, the form can include permission for credit entries to correct errors, such as reversing an incorrect debit or issuing a refund. The language should be limited to corrections so it cannot be interpreted as permission for unrelated transfers. It can also include a place to record a correction reference ID, which helps reconciliation and customer support. The goal is a smoother resolution process when errors occur. A narrow correction clause protects the payer by limiting credits to corrections and protects the business by documenting consent to fix mistakes without delays.
How should a business document internal approvals for initiating ACH debits?
Internal approvals can be documented by assigning a customer reference ID and recording who reviewed the authorization, when it was received, and what payment type was selected. A short internal approval block can also capture the billing owner and the effective start date used for scheduling. This helps prevent debits from being initiated before the authorization is effective or from the wrong customer file. If the payer later questions a debit, an internal approval record makes it easier to confirm that staff followed the correct process. The goal is consistent operational control, especially when more than one team member can initiate entries.
Can one authorization cover multiple services or locations for the same payer?
It can, but the form should clearly identify the account references or service identifiers covered by the authorization. Without a limitation field, multi-service relationships can lead to confusion about which debits were intended. A table listing covered accounts or invoice prefixes can help, especially for business payers with multiple sites. If the payer wants separate caps or schedules for different services, separate authorizations or separate modules can keep the terms clear. The goal is to avoid accidental cross-charging and to make reconciliation straightforward. Clear scope fields are the best protection when billing is more complex than one subscription.
What is a best practice for storing ACH authorization forms securely?
Best practice is to store the signed authorization in a controlled location with access limited to staff who need it for billing and support. Assigning a reference ID and recording where the form is stored helps prevent copies from being scattered across email threads. If you update bank details, keep the old version and label the new one with an effective date so the history is clear. Retaining cancellation notices and correction documentation in the same file also helps. The goal is to maintain a complete, organized record while reducing unnecessary exposure of sensitive bank details.
Can AI Lawyer help customize the authorization for portal-based billing?
AI Lawyer can help you tailor the form to portal-based workflows by adding fields for portal account IDs, invoice references, notice preferences, and internal approval tracking. You can also include a transaction profile table for variable billing so the payer sees the cap and the method for identifying each debit. You still control how invoices are generated and how debits are initiated, but a structured template helps staff follow the same steps every time. When a portal is used, consistent reference fields can reduce support tickets because payers can match debits to portal statements more easily.
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