RECURRING BANK (ACH) PAYMENT AUTHORIZATION

You authorize regularly scheduled withdrawals from your bank account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you, and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least ten (10) days in advance of the payment being collected.

I, [CUSTOMER NAME], authorize [MERCHANT NAME] to charge my bank account indicated below for $[AMOUNT] on the [#] day of each [FREQUENCY] (week, month, etc.)

This payment is for the following: [REASON FOR RECURRING PAYMENT].

BILLING INFORMATION

Billing Address: [STREET ADDRESS] City, State, ZIP: [CITY, STATE, & ZIP]
Phone #: [CARDHOLDER PHONE] Email: [CARDHOLDER EMAIL]

BANK DETAILS

Account Type: ☐ Savings | ☐ Checking
Account Name: [ACCOUNT NAME]
Bank Name: [BANK NAME]
Account Number (#): [ACCOUNT NUMBER] Routing Number (#): [ROUTING NUMBER]

ACCOUNT HOLDER SIGNATURE

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the Merchant, in writing, of any changes to my account or my request to terminate this authorization at least fifteen (15) days before the next billing date. If the above-noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the Merchant may, at its discretion, attempt to process the charge again within thirty (30) days. I agree to an additional $[NSF CHARGE] charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank, so long as the transactions correspond to the terms indicated in this authorization form.

Account Holder’s Signature: ________________________________ Date: [MM/DD/YYYY]

Printed Name: [CUSTOMER NAME]