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One-Time ACH Debit Authorization Template
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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: ___________________________
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One-Time ACH Debit Authorization Template
ONE-TIME ACH DEBIT AUTHORIZATION TEMPLATE FAQ
What is a one-time ACH debit authorization?
A One-Time ACH Debit Authorization is a written permission allowing a business to withdraw a single specified amount from a customer’s bank account via ACH. It is commonly used for invoice payments, deposits, fees, or one-time purchases.
How is it different from recurring authorization?
A one-time authorization permits only one debit for a stated amount on (or around) a specified date. A recurring authorization allows repeated debits on a schedule. This template is strictly for single transactions.
What should it include?
Include: payer details, bank account details, debit amount, debit date, description, and a signature. This template also includes a short dispute/contact section and encourages secure handling of banking details.
Can the payer revoke authorization?
Often the payer can revoke before the debit is processed, depending on timing and bank rules. This template includes a customizable revocation cutoff time.
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