ACH Payment Authorization Form
I
(Full name)
authorize
(Company name)
to initiate ACH charges / debits to the financial institution listed below for services.
Billing Information
Bank Details
Pay to the order of
For
⑆021234567⑆001234567〃243
Routing
number
number
Account
number
number
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to provide written notification of any changes in my account information or termination of this authorization. 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 transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.
Signature
(Account holder's signature)
Date
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