ACH Authorization Form

Automated Clearing House Payment Authorization

This form authorizes the entity named below to initiate electronic entries to your account via the Automated Clearing House (ACH) system.

1. Account Holder Information

Full Legal Name *

Business/Company Name (if applicable)

Social Security Number / Tax ID

Phone Number *

Email Address *

Mailing Address *

Street Address

City

State

ZIP Code

2. Financial Institution Information

Financial Institution Name *

Bank Address (City, State)

Routing Number (9 Digits) *

Account Number *

Account Type *

Checking

Savings

NOTE: Please attach a voided check or official bank letter for account verification purposes.

3. Authorization Type

One-Time Payment

Recurring Payments

Direct Deposit (Credits)

ACH Debits (Payments)

4. Payment Details (If Applicable)

Amount ($)

Frequency

Start Date

5. Terms and Authorization Agreement

Authorization: I hereby authorize the Company to initiate entries to my checking/savings account at the financial institution listed above, and initiate adjustments for any transactions credited/debited in error. This authority remains in effect until the Company is notified in writing to cancel it.

NACHA Compliance: I acknowledge that ACH transactions must comply with U.S. law and NACHA rules.

Revocation: This authorization remains in effect until I notify the Company in writing at least thirty (30) days prior to cancellation.

Error Correction: In the event of an error, I authorize the Company to debit or credit my account to correct it. The Company reserves the right to refuse or terminate services.

Privacy: All information will be kept secure and used solely for processing authorized transactions.

6. Acknowledgment and Signature

I have read and agree to the terms and conditions outlined above. *

Authorized Signature

Printed Name

Title/Position (If Business)

Date