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One (1) Time Bank (ACH) Payment Authorization Form

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one (1) time bank (ACH) payment authorization form gives a business permission to make a single withdrawal from a customer’s checking or savings account. The document includes the amount ($) to be withdrawn, the date of withdrawal, the billing information of the customer (including their banking info), and the customer’s legally binding signature. While optional, the merchant can add a fee should the withdrawal result as a Non-Sufficient Funds (NSF) payment.

How to Write

Download: Adobe PDF, MS Word (.docx), OpenDocument (.odt)

Step 1 – General Info

To start, enter the following information at the top of the page:

  • The full name of the customer (person authorizing the withdrawal);
  • The full name of the merchant (will most likely be the name of a company);
  • The amount ($) of the withdrawal;
  • The date (mm/dd/yyyy) the withdrawal will occur; and
  • The purpose of the payment (what the customer is receiving in exchange).

Step 2 – Billing Information

The next section is for recording the customer’s billing information. There are four (4) fields, two (2) of which are required.

  • The customer’s billing address;
  • The customer’s city, state, and ZIP code;
  • Their phone number (optional); and
  • Their email address (also optional).

Step 3 – Bank Details

  • Select whether the customer’s bank account is a checking or saving’s account;
  • Type the name of the bank account (ex: “Chase personal checking account”);
  • Enter the name of the bank (ex: “Bank of America”);
  • Enter the account number; and
  • Type the bank’s full routing number.

Step 4 – Customer Signature

Finally, the customer will need to sign their name onto the document, enter the date they signed, and write their full printed name. Signing can take place through eSign, or by printing the document and signing in black or blue ink.