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ApplyMerchant/Payee Name: [Business Name]
[Address]
[Phone] | [Email]
[Website (Optional)]
Payer Name: [Full Name/Business]
Invoice/Reference Number (Optional): [__]
Date: [Date]
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.
2.1 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).
3.1 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): [____]
4.1 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].
5.1 Bank information will be used only to process this one-time payment and stored securely with limited access.
Payer / Authorized Representative: [Full Name]
Date: [Date]
Signature: ___________________________
Merchant Representative (Optional): [Name]
Date: [Date]
Signature: ___________________________
Each template already follows legal structure and best practices.
The agreement is automatically filled and adapted to your inputs.
Check the generated document, make edits if needed, and download a ready-to-use agreement.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Frequently asked
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.
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.
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.
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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