Authorization for ACH Payment

Sample Merchant
123 Elm Street
Anytown, CA 92111
800-555-5555

RE: ACH Authorization

In consideration of the goods, products and/or services provided to me by MERCHANT, as listed above, I hereby authorize MERCHANT to initiate a debit entry to my checking account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account for the amount listed below. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

Depository Bank Name:
_______________________________________________________

Branch (City, State, Zip):
_______________________________________________________

Account Number: ___________________ Routing Number: __________________
[ ] Checking [ ] Savings

How to find your Routing and Account Numbers

Amount: $______________________________

Effective Date: ____/____/____ (mm/dd/yyyy)

This authorization is to remain in full force and effect for this transaction only, or until such time that my indebtedness to MERCHANT for the amount listed above is fully satisfied. The specific debit to my account authorized herein may only post on or after the EFFECTIVE DATE listed above, and in no event may the debit transaction post to my account prior to said date. I may only revoke this authorization by contacting MERCHANT directly at the address and phone number listed above, and only in the case that I return the goods, products and/or services provided to me by MERCHANT pursuant to their particular return policy in effect the date this authorization is granted. I further understand that, if funds are not available in my account on the date of the debit transaction, I will be charged a “Returned Check” fee under applicable state law.

Name: ____________________________________ (Please Print)
Date: ___ /____ /____
Signature: _________________________________

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