One-Time ACH Debit Authorization Template

Merchant/Payee Name: [Business Name]
[Address]
[Phone] | [Email]
[Website (Optional)]

Payer Name: [Full Name/Business]
Invoice/Reference Number (Optional): [__]
Date: [Date]

1. Authorization

1.1 I authorize [Merchant Name] to initiate a one-time ACH debit from my bank account as described below.
1.2 This authorization is for a single transaction only.

2. Debit Details

2.1 Debit Amount: $[Amount]
2.2 Debit Date: [Date] (or “on or after [Date]”)
2.3 Purpose/Description: [Invoice payment, deposit, fee, etc.].
2.4 Return/NSF Fee (Optional): $[__] (if permitted).

3. Bank Account Information (Handle Securely)

3.1 Account Holder Name: [Name]
3.2 Bank Name: [Bank]
3.3 Account Type: ☐ Checking ☐ Savings
3.4 Routing Number: [Routing]
3.5 Account Number: [Account No.]
3.6 Last 4 digits (for confirmation): [____]

4. Revocation and Questions

4.1 To revoke this authorization before processing, I will notify [Merchant Name] by [Time] on [Date] at [Email/Phone].
4.2 If I have questions about this payment, I will contact [Merchant Name] at [Email/Phone].

5. Data Handling (Optional)

5.1 Bank information will be used only to process this one-time payment and stored securely with limited access.

Signatures

Payer / Authorized Representative: [Full Name]
Date: [Date]
Signature: ___________________________

Merchant Representative (Optional): [Name]
Date: [Date]
Signature: ___________________________