The ACH Rules governing a payment or series of payments which are authorized by a payer as part of a written notification, agreement or contract require that certain disclosures be made and certain information be collected as a part of that agreement.
Best practices dictate that the ACH Payment Authorization be evidenced by a separate signature from the payer wherein the payer is specifically acknowledging the payment authorization as opposed to simply incorporating the authorization language into the body of the agreement or contract.
Example if authorization is for a single payment:
Company Name
I hereby authorize (Business or Entity Name), to initiate an electronic debit withdrawal from my account with the Financial Institution indicated below in the amount of $_______ for the purpose of (description of the purpose of the payments). Furthermore, I assert that I am the owner or an authorized signer of this bank account.
The effective date of the withdrawal debit will be (Date)
Type of Account: ☐ Checking Account ☐ Savings Account
Financial Institution Name:
Financial Institution City and State:
Name on Account:
Transit/ABA No.
Account No.
Please sign and date this authorization below.
Your Signature
Today’s Date
If I have any questions or concerns in regard to this payment or the payment does not occur on the date or in the amount authorize, or you wish to rescind this authorization, I can call (Customer Service Phone Number) during the following business hours: (Business Hours)
Note: You may wish to request a voided check or in order to verifying that the routing and account number above is accurate and that the bank account is, in fact, in the name of the payer.
Proof of Authorization:
A copy of the signed authorization
Example if the authorization is for a series of recurring payments or payments as due:
I hereby authorize (Business or Entity Name) to initiate debit withdrawal entries from my account with the Financial Institution indicated below for the purpose of collecting payments in regard to (description of the purpose of the payments) or other charges as they become due and payable under the terms and conditions of the attached (Agreement or Contract). [If practical the specific frequency (weekly, quarterly or annually) and/or date of the month the payment will be effective should be indicated]. Example:
The payments which I am authorizing will be withdrawn from my account on the (Day of the Month). If that day falls on a weekend or bank holiday, the withdrawal shall occur on the next business banking day.
This authority is to remain in full force and effect until (Business or Entity Name) has received notification from me of its termination in such time and in such manner as to afford (Business or Entity Name) and the Financial Institution a reasonable opportunity to act upon it. Furthermore, I assert that I am the owner or an authorized signer of this bank account
I have verifies with the Financial Institution that the account indicated below is capable of receiving an ACH Debit or Credit item.
Type of Account: ☐ Checking Account ☐ Savings Account
Financial Institution Name:
Financial Institution City and State:
Name on Account:
Transit/ABA No.
Account No.
Please sign and date this authorization below.
Your Signature
Today’s Date
If I have any questions or concerns in regard to these payments, the payments do not occur on the dates or in the amounts authorized or I wish to rescind this authorization, I can call (Customer Service Phone Number) during the following business hours: (Business Hours)
Note: You may wish to request a voided check or in order to verifying that the routing and account number above is accurate and that the bank account is, in fact, in the name of the payer.
Proof of Authorization:
A copy of the signed authorization
