One Time Ach Payment Authorization Form

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ONE TIME ACH PAYMENT AUTHORIZATION FORM
Sign and complete this form to authorize Los Angeles Federal Credit Union (“LAFCU”) to make a one-
time ACH debit to your business bank account for your company in conjunction with a loan funded
through the Energy Loan Network loan referral program.
By signing this form you give LAFCU permission to debit your account for the amount indicated on or
after the indicated date. This is permission for a single transaction only and does not provide
authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
_______________________________ authorizes LAFCU to charge its business bank account
indicated below for _______________________________ on or after ________________________.
(amount)
(date)
Company Name ____________________________ (“Company”)
Billing Address ____________________________
Phone# ________________________
City, State, Zip ____________________________
Email
________________________
Company Name on Account: _______________________________
Bank Name: _______________________________
Bank Account Number: _______________________________
Bank Routing #: _______________________________
Bank City/State: _______________________________
This Business Bank Account is Enabled for ACH Transactions
Yes
No
I certify that I am an authorized representative of the Company indicated above and that I have the authority to authorize this payment
on the Company’s behalf. Company understands that because this is an electronic transaction, these funds may be withdrawn from
its account as soon as the above noted transaction date, and that it will have limited time to report and dispute errors. In the case that
the transaction is returned for Non-Sufficient Funds (NSF) Company understands that LAFCU may at its discretion attempt to process
the charge again within 30 days, and agrees to an additional $35.00 charge for each attempt returned NSF, which will be initiated as
a separate transaction from the authorized payment. Company has certified that the above business bank account is enabled for ACH
transactions, and agrees to reimburse LAFCU for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits
or credits as a result of the account not being properly configured for ACH transactions. Both parties agree to be bound by
NACHA Operating Rules as they pertain to this transaction. Company acknowledges that the origination of ACH transactions
to its account must comply with the provisions of U.S. law. Company agrees not to dispute this transaction with its bank provided the
transaction corresponds to the terms indicated in this authorization form.
SIGNATURE __________________________________________
DATE ____________________
NAME _______________________________________________
TITLE ____________________
AUTHORIZED BY:______________________________________ DATE ____________________
Consumer Loans Department
***THIS DOCUMENT MUST ACCOMPANY VERIFICATION OF ACCOUNT***
(Acceptable verification of account includes copy of voided check, bank statement, or bank letter)

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