Authorization for Direct Payment via ACH (ACH Debit)
I/we hereby authorize __________________________, hereinafter called COMPANY, to originate debit entries to my/our account (and, if necessary, electronically credit my/our account to correct erroneous debits) as indicated below for the purpose of making a payment. I/we acknowledge the origination of ACH transactions to my/our account must comply with the provisions of U.S. law.
__________________________ _____________________ _________________________
Financial Institution Routing/Transit Number Account Number
Account Type: _______ Checking _______ Savings
____________________________
Amount of debit(s)
If amount not pre-determined, method of determining amount of debit(s), or range of acceptable dollar amounts authorized:
_____________________________________________________________________________________________________
_________________________________________________________
Date(s) and/or Frequency of Debits
This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY a reasonable opportunity to act on it.
__________________________ __________________________
Print Individual Name Print Individual Name
__________________________ __________________________
Signature Signature
_______________ _______________
Date Date