ACH Authorization Form


As a duly authorized check signer on the financial institution account identified below, I authorize (Company Name) to perform scheduled or periodic electronic funds transfer debits and/or credits from my account identified below for payments due or when applicable, apply electronic funds transfer credits to the same. This applies to check by phone payments as well as any other electronic payment.

Furthermore, if any such electronic debit(s) should be returned by my financial institution as Non-Sufficient Funds ( NSF ), I authorize, (Merchant) _______________________, Inc., to collect a returned item fee of $20.00 per item by electronic debit from my account identified below.

For accounting purposes, all electronic debits will be reflected in the monthly bank statement that corresponds with the financial institution account identified below.

I understand and authorize all of the above as evidenced by my signature below.

AUTHORIZING SIGNATURE: _________________________________ DATE: _______________