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ACH Payment Authorization Form Template

The document is an ACH payment authorization form for clients of the Florida Institute of 10400 Eureka Park, LLC. It requests specific banking information from clients to process payments and outlines the terms of authorization. Clients must provide their company name, account details, and sign to authorize transactions, which remain effective until revoked in writing.

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Mary Cuban Figure
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30 views1 page

ACH Payment Authorization Form Template

The document is an ACH payment authorization form for clients of the Florida Institute of 10400 Eureka Park, LLC. It requests specific banking information from clients to process payments and outlines the terms of authorization. Clients must provide their company name, account details, and sign to authorize transactions, which remain effective until revoked in writing.

Uploaded by

Mary Cuban Figure
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Members of the Florida Institute of

10400 Eureka Park, LLC


5727 NW58057thBlue Lagoon Drive, Suite 200
St #303
Certified Public Accountants

Members of the American Institute of


Certified Public Accountants
Miami, FLMiami, FL 33126
33126
Tel 305.448.3898
Tel: (305)570-2277 | Fax: 305.443.9073
/ (305)305-2600810 Members of the National Association
[Link]
lasvillasdesegovia@[Link] of Certified Valuators and Analysts

Dear clients,

In order to process all ACH payments, we will need you to give us the following information:

Company name: ___________________________________________________

I (we) hereby authorize _______________________________ to initiate credit entries to my (our)

Checking Account

Savings Account

Personal Account

Indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to credit the
same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply
with the previsions of U.S. law.

Depository name: _____________________________________________________________________

Branch: _____________________________________________________________________________

City: _______________ State: ___________ ZIP: ___________

Routing number: _________________________ Account number: ______________________________

Services rendered: _________________________________ Effective date: _____________________

One time fee Amount: _________


Recurring fee Amount: _________ Rate: Monthly Quarterly Annually

This authorization is to remain in full force and effect until ________________________________ (Company)has
received written notification from me (or either of us) of its termination in such time and in such manner as
to afford _______________________________ (Company) and DEPOSITORY a reasonable opportunity to act on it.

Name(s) __________________________

Signature _________________________

Date _____________________________

Note: WRITTEN ACH AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE
AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE
AUTHORIZATION. ALL AUTHORIZATIONS MAY BE ALTERED BY A WRITTEN CONSENTMENT SUCH AS AN
EMAIL OR FAX AUTHORIZING A NEW AMOUNT.

Member of Russell Bedford International


A Global Network of Independent Professional Services Firms

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