Ach Authorization Form
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1ACH Authorization Form
Choose Your Option Below:
Recurring Billing
In consideration of the goods, products and/or services provided to me by
, as listed below. I hereby
authorize
t o initiate a debit entry to my checking account indicated below at the depository financial
institution named below, hereinafter called Client Bank, and to debit the same to such account for the amount listed below. This
authorization will continue until revoked in writing.
Single Billing
In consideration of the goods, products and/or services provided to me by
a s listed below, I hereby
authorize
to initiate a debit entry to my checking account indicated below at the depository financial
institution named below, hereinafter called Client Bank, and to debit the same to such account for the amount listed below. This
authorization will continue until revoked in writing.
Name:
Client Bank Name:
Address:
Account Holder Name:
City/State/Zip
Last 4 Digits of Account #:
Phone:
Bank Routing Number:
*I hereby assert that I am either the rightful and legal owner or I am a duly authorized signer on the account with the power to authorize these transactions*
Billing Conditions: _ ___________________________________ (as per defined agreement terms)
Print Name: _ _______________________________________
Signature: _ _________________________________________
D ate: _ ____________________
By signing this agreement, I hereby authorize _________________________________ to electronically debit the checking or savings account indicated above for
payments due under this agreement. I understand the effective date of these electronic debits to my account will be the business day on which the
payment is due or scheduled per this agreement. I understand that if the debit is returned unpaid due to insufficient funds or my banks electronic draft
restrictions, I may be charged a $25.00 NSF Penalty for the returned item.
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Parent category: Business