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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 each ________________. (week, month, etc.) This payment is for ________________________________. (Description of Goods/Services) Billing Information Billing Address ___________________________ City, State, Zip ___________________________ Bank Details ☐ Checking ☐ Savings Account Name _________________________ Bank Name _________________________ Account Number _________________________ Routing Number _________________________ (Amount $) (day) 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debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.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) Phone # ______________________ Email ________________________ Page 1 of 1
Signature (example: /John Doe/)
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