ACH Authorization Form

ACH Authorization Form

  • Customer Information

  • (Company Name)
  • I understand that, if necessary, an adjusting debit or credit entry may be made to correct an error.

    I also authorize the financial institution named below to credit and/or debit my account for the correcting entries. I duly certify that I am an authorized signer of said account and have the right to enter into this agreement.
  • Account Information

  • *If the payment date falls on a nonbanking day, the debit will post on the next available banking day.
  • OR
  • (i.e. Full Balance, % of balance, customer provided instruction, etc)
  • (Company Name)
  • has received written notification from me that the draft authorization has been revoked. It is further provided that written notification of termination, by either party, shall be provided in such time and manner as to afford either party reasonable opportunity to act on it.
  • Signature of account owner
  • Date Format: MM slash DD slash YYYY
    Date