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Recurring ACH Debit Authorization Template
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Recurring ACH Debit Authorization Template
Merchant/Payee Name: [Business Name]
[Address]
[Phone] | [Email]
[Website (Optional)]
Payer Name: [Full Name/Business]
Account/Customer ID (Optional): [__]
Date: [Date]
1. Authorization Type
1.1 Debit Type (Select One):
☐ Fixed recurring amount
☐ Variable recurring amount (amount may change)
2. Bank Account Information (Handle Securely)
2.1 Account Holder Name: [Name]
2.2 Bank Name: [Bank]
2.3 Account Type: ☐ Checking ☐ Savings
2.4 Routing Number: [Routing]
2.5 Account Number: [Account No.]
2.6 Last 4 digits (for confirmation): [____]
3. Debit Schedule and Amount
3.1 Start Date: [Start Date]
3.2 Frequency: ☐ Weekly ☐ Biweekly ☐ Monthly ☐ Quarterly ☐ Annually ☐ Other: [Frequency]
3.3 Amount (If Fixed): $[Amount] per debit.
3.4 Amount (If Variable): Based on: [Usage/plan], calculated as: [Method].
3.5 Maximum Debit (Optional): $[Max] per billing cycle.
3.6 Payment Description: [Membership, invoice, loan payment, etc.].
4. Notice of Changes (Optional)
4.1 If the amount changes, Merchant will provide notice: ☐ [__] days before debit ☐ via email ☐ via invoice ☐ other: [Method].
5. Returned Payments and Fees (Optional)
5.1 If a debit is returned, Merchant may retry [] times.
5.2 Returned payment/NSF fee: $[] (if permitted).
6. Cancellation / Revocation
6.1 To cancel, Payer must provide written notice by: ☐ email ☐ phone ☐ online portal ☐ mail to [Contact].
6.2 Notice must be received at least [__] business days before the next scheduled debit to stop that debit.
7. Data Handling (Optional)
7.1 Bank information will be used only for processing payments 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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Recurring ACH Debit Authorization Template
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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.
RECURRING ACH DEBIT AUTHORIZATION TEMPLATE FAQ
What is a recurring ACH debit authorization?
A Recurring ACH Debit Authorization is a written permission allowing a business to withdraw funds from a customer’s bank account on a recurring schedule. It’s commonly used for memberships, subscription services, installment plans, loan payments, and ongoing service fees.
Can the amount change over time?
Yes, but variable amounts should be disclosed clearly, including how amounts are determined and what notice will be provided. This template includes both fixed and variable amount options and a maximum debit (optional).
How does cancellation work?
Customers typically can revoke authorization by giving written notice before the next debit, subject to timing requirements. This template includes a notice period field and a cancellation contact method.
What should the authorization include?
Include: account holder details, bank details, debit schedule, start date, amount or calculation method, and signature. This template also includes a “returned payment” section and secure data handling notes.
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