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Recurring ACH Payment Authorization Form

This document is an authorization form for recurring ACH payments, allowing a merchant to charge a specified amount to the customer's bank account on a scheduled basis. The customer agrees to provide written notice for any changes or cancellations and acknowledges the terms regarding insufficient funds and transaction processing. The form includes sections for personal, billing, and bank details, as well as a signature line for the account holder.

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makenziej227
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10 views1 page

Recurring ACH Payment Authorization Form

This document is an authorization form for recurring ACH payments, allowing a merchant to charge a specified amount to the customer's bank account on a scheduled basis. The customer agrees to provide written notice for any changes or cancellations and acknowledges the terms regarding insufficient funds and transaction processing. The form includes sections for personal, billing, and bank details, as well as a signature line for the account holder.

Uploaded by

makenziej227
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

Recurring ACH Payment Authorization

You authorize regularly scheduled charges to your checking/savings account. You will
be charged the amount indicated below each billing period. A receipt for each payment
will be provided 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.

I _______________________ authorize _________________________ to charge my


(Full Name) (Merchant’s Name)

bank account indicated below for $________________ on the ________________ of


(Amount $) (day)
each ________________.
(week, month, etc.)

This payment is for ________________________________.


(Description of Goods/Services)
Billing Information

Billing Address ___________________________ Phone # ______________________

City, State, Zip ___________________________ Email ________________________

Bank Details

☐ Checking ☐ Savings

Account Name _________________________


Bank Name _________________________
Account Number _________________________
Routing Number _________________________

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify
________________ 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 payment dates fall on a
weekend or holiday, I understand that the payments may be executed on the next business day. For ACH
debits to my checking/savings account, I understand that because these are electronic transactions,
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
________________ may at its discretion attempt to process the charge again within 30 days, and
agree to an additional $________________ 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 certify that I
am an authorized user of this bank account and will not dispute these scheduled transactions with my
bank; so long as the transactions correspond to the terms indicated in this authorization form.

SIGNATURE ___________________________ DATE _____________________


(Account Holder’s Signature)

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