Authorization for Recurring ACH Payments
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 payment 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: _______________________________________________________ How to find your Routing and Account Numbers
Total Amount: $___________ This authorization is to remain in full force and effect until such time that my indebtedness to MERCHANT for the total amount listed above is fully satisfied. The specific debit to my account authorized herein may only post on or after the EFFECTIVE DATE /PAYMENT FREQUENCY AGREEMENT listed above, and in no event may the debit transaction post to my account prior to said date or the Payment Frequency Agreement as shown above. 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) |
