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: ___________________________