Auto Debit Authorization Form
The Graphic below is the brief document consumers and businesses
sign to authorize Automatic ACH Debits and to authorize Point
of Sale Check Conversion Debits from their accounts.
AUTHORIZATION FOR DIRECT PAYMENT (DEBIT)I authorize(Company Name) ______________________________ and the financial institution named below to initiate one ACH entry to my checking/savings account, in the amount of $________. This authority will remain in effect until I notify you, in writing, to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution three (3) days before my account is charged. If the debit is returned unpaid, Merchant may debit returned item fees, as posted, from my account in the same manner. ______________________________________________________________(NAME OF FINANCIAL INSTITUTION) (BRANCH) ______________________________________________________________ (CITY) (STATE) (ZIP CODE) ______________________________________________________________ (SIGNATURE) (DATE) ______________________________________________________________ (NAME - PLEASE PRINT) ______________________________________________________________ (ADDRESS - PLEASE PRINT) Account No. _________________________________ Checking ____ Savings _____ Financial Institution Routing Number ______________________________________ (Between these Symbols I: I: on the bottom left of your check) Fax with a VOIDED check to:555-555-5555 RETAIN FOR YOUR RECORDS On________________(DATE) I authorized ________________________________ (COMPANY) at__________________________________________________________ (ADDRESS) Phone _____________________ to initiate electronic entries to my checking/savings account and agree to the terms listed on the authorization. I may revoke my authorization with the company at any time by writing to the address above. Initial payment Amount $__________ Regular payment Date __________(If payment changes we will notify you at least10 days prior to scheduled payment date.) |
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