ACH Authorization Form Template: Bank Details, Consent & Revocation

Business/Payee:

[Company Name]

Address: [Company Address]

Contact Information: [Phone, Email]

Customer/Payor:

[Full Name]

Address: [Company Address]

Phone: [Customer Phone]

Email: [Customer Email]

1. Authorization

I hereby authorize [Company Name] to initiate electronic debit entries from my bank account listed below, and if necessary, credit entries for error corrections. This authorization applies to: This authorization is effective beginning:

• One-time payment of$[Amount]

2. Bank Account Information

• Bank Name: ____________________________
• Account Type: ☐ Checking
• Routing Number: ________________________
• Account Number: ________________________

3. Effective Dates

This authorization is effective beginning [Date] and will remain in effect until: Revoked in writing by the Payor with at least business days' notice..

4. Terms and Conditions

• I understand that payments may be rejected for insufficient funds or incorrect account details.
• I am responsible for any bank fees incurred due to failed transactions.
• I acknowledge that this authorization does not modify my obligations under any related contract or agreement with [Company Name].

5. Cancellation

This authorization is effective beginning [Company Name] business days before the next scheduled payment.

6. Signature