Sample Authorization for Direct Payment via ACH (ACH Debit)

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Sample Authorization for Direct Payment via ACH (ACH

Debit)

CONSUMER AUTHORIZATION FOR DIRECT PAYMENT VIA ACH (ACH DEBITS)

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose

of making a payment.

I (we) authorize ________________________ (“COMPANY”) to electronically debit my (our) account (and,

if necessary, electronically credit my (our) account to correct erroneous debits

) as follows:

Select One:

❏

Checking Account

❏

Savings Account

at the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH

transactions I (we) authorize comply with all applicable law.

Depository Name ____________________________________

Routing Number _____________________________________

Account Number ____________________________________

Amo unt of debit(s) or method of determining amount of debit(s) [or specify range of acceptable

dollar amounts authorized]: ______________________________________________.

Date(s) and/or frequency of debit(s): ______________________________________________.

I (we) understand that this authorization will remain in full force and effect until I (we) notify

COMPANY [insert manner of revocation, i.e., in writing, by phone, location, address, etc.] that I (we)

wish to revoke this authorization. I (we) understand that COMPANY requires at least [X

The NACHA Operating Rules do not require the consumer’s express authorization to initiate Reversing Entries to correct erroneous

transactions. However, Originators should consider obtaining express authorization of debits or credits to correct errors.

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days/weeks] prior notice in order to cancel this authorization.

Name(s) _____________________________________________________________________________(Please Print)

Date __________ Signature(s) __________________________________________________________

Written debit authorizations must provide that the Receiver may revoke the authorization only by notifying the Originator in the time

and manner stated in the authorization. The reference to notification should be filled with a statement of the time and manner that

notification must be given in order to provide company a reasonable opportunity to act on it (e.g., “In writing by mail to 100 Main

Street, Anytown, NY that is received at least three (3) days prior to the proposed effective date of the termination of authorization”).