Gratis 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"