Ach Payment Authorization Form printable pdf download

ACH Payment Authorization Form

Schedule a one-time or recurring payment to be automatically deducted from your checking or savings

account. Just complete and sign this form to get started!

Here’s How ACH Payments Work:

You authorize a one-time or regularly scheduled charge to your checking or savings account. You will

be charged the amount shown below on the date or schedule indicated. A receipt for each payment

will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You

agree that no prior-notification will be provided unless the date or amount changes, in which case you

will receive notice from us at least 10 days prior to the payment being collected.

Please complete the information below:

I ____________________________ authorize

CapitalCredit LLC

to charge my bank account

(full name)

indicated below for the following one-time or scheduled amount for payment of my loan:

Amount: ________________

One Time Payment

Recurring Payment Schedule

One Time Payment Date: ________________

Start Date: ________________

$10 charge applies to all One time payments!

End Date: ________________

Frequency: ________________

Bank Account

Billing Address

Billing Address: ___________________________

Checking

Savings

Name on Acct:

____________________

City: ____________________________

Bank Name:

____________________

State: _________

Account Number: ____________________

Zip Code: ______________

Bank Routing #: ____________________

Phone#: ________________________

Bank City/State: ____________________

Email: ________________________

SIGNATURE

DATE

For a One Time Payment this authorization is for a single transaction on or after the indicated date. For a Recurring Payment Schedule, I understand

that this authorization will remain in effect until I cancel it in writing, and I agree to notify

CapitalCredit

in writing of any changes in my account

information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a

weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic

transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction

being rejected for Non Sufficient Funds (NSF) I understand that

CapitalCredit

may at its discretion attempt to process the charge again within 30 days,

and agree to an additional

CapitalCredit

charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized

recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to

dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

Ach Payment Authorization Form

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