ACH Debit Authorization

ACH DEBIT AUTHORIZATION

Payee: [LEGAL NAME], [ADDRESS], [BILLING PHONE AND EMAIL] ("Payee")

Account holder: [FULL LEGAL NAME], [ADDRESS], [EMAIL] ("Account Holder")

Agreement or invoice being paid: [DESCRIPTION AND IDENTIFIER]

Complete the payment terms and bank account identification before signing. Payee will give Account Holder a completed copy of this signed authorization.

1. Authorized debit

Account Holder authorizes Payee to initiate ACH debits from the account identified in Section 2 for the obligation above, subject to the selection below. Payee may not use this authorization for a different debt or a different amount or schedule except as expressly selected here or later agreed in a new authorization.

Select one:

☐ One-time debit: $[AMOUNT] on or after [DATE]. This authorization ends when that debit is completed or cancelled.

☐ Recurring fixed debit: $[AMOUNT] every [WEEK / MONTH / OTHER], on [DAY OR DATE], beginning [DATE] and ending [DATE / AFTER NUMBER OF PAYMENTS / WHEN REVOKED]. If a scheduled date is not a banking day, the debit will occur [NEXT BANKING DAY / OTHER AGREED DATE].

☐ Recurring variable debit: The amount is determined by [ATTACHED AGREEMENT OR FORMULA], with a maximum of $[AMOUNT] per debit, every [PERIOD] on [DAY OR DATE], beginning [DATE] and ending [DATE / WHEN REVOKED]. Payee will give Account Holder written notice of the amount and date at least 10 days before a consumer debit that varies from the prior debit or authorized amount, as described in 12 C.F.R. § 1005.10(d)(1). Notice will be sent to [EMAIL / POSTAL ADDRESS].

Number of debits authorized: [ONE / NUMBER / UNTIL END DATE]. Total maximum authorized: $[AMOUNT / FORMULA / NOT APPLICABLE]. Any agreed processing charge must be stated separately here: [AMOUNT AND TRIGGER / NONE].

2. Account identification

Financial institution: [NAME]

Account type: ☐ Checking ☐ Savings ☐ Other: [____]

Account name: [NAME AS HELD BY THE INSTITUTION]

Routing number and account number: Supplied through [PAYEE'S SECURE PAYMENT PORTAL / ENCRYPTED BANK-DETAILS ADDENDUM] on [DATE]. Account ending in: [LAST FOUR DIGITS]. The full numbers are not part of this circulated form.

Account Holder confirms that the identified account is an account Account Holder is authorized to debit. Payee will use the account details only for the authorized debits and any agreed reversal or refund.

3. Changes, cancellation, and errors

Account Holder may revoke this authorization by sending notice to [PAYEE EMAIL AND POSTAL ADDRESS] at least [NUMBER] business days before the next scheduled debit. Payee will confirm receipt and the effective date at [EMAIL OR PHONE]. Revocation stops future debits under this authorization; it does not by itself cancel the underlying obligation. The parties will arrange another payment method for any balance due.

For a preauthorized debit from a consumer account, Account Holder may also instruct the financial institution to stop payment by notifying it orally or in writing at least three business days before the scheduled transfer under 12 C.F.R. § 1005.10(c)(1). This form does not limit that right. Account Holder should report a questioned debit promptly to [PAYEE BILLING CONTACT] and to the financial institution.

A change to the account, debit amount, schedule, or payee requires a new written authorization, except for a variable amount expressly authorized in Section 1. Payee will return any duplicate or erroneous debit by [METHOD AND AGREED RESPONSE PERIOD], subject to applicable law and the financial institution's process.

4. Signature

By signing, Account Holder authorizes only the selected debit terms above and acknowledges receipt of a completed copy of this form by [EMAIL / PAPER] on [DATE].

Account Holder signature: [____________________________] Date: [__/__/____]

Printed name: [____________________________]

Payee representative, acknowledging receipt: [____________________________] Date: [__/__/____]

Source

• Consumer Financial Protection Bureau, 12 C.F.R. § 1005.10(b), (c)(1), (d)(1): https://www.consumerfinance.gov/rules-policy/regulations/1005/10/