<Insert Logo Here>
< Street Address>
< City State Zip>
< Phone Number>

One Time ACH Payment Authorization Form

Sign and complete this form to authorize <insert business name> to make a one time debit to your checking or savings account.  

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.  This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I ____________________________ authorize <Insert Business Name> to charge my bank account  	                      
                    (full name)

indicated below for _____________  on or after ___________________.
                                        (amount)                                               (date)

	  	                        

Billing Address	____________________________		Phone#	________________________
City, State, Zip ____________________________		 Email	________________________	

Account Type:     Checking            Savings

Name on Acct 	_______________________________
Bank Name 	_______________________________
Account Number	_______________________________
Bank Routing #	_______________________________
Bank City/State   _______________________________ 	

SIGNATURE 								DATE 				 

I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of  the payment being rejected for Non Sufficient Funds (NSF) I understand that <insert your company name> may at its discretion attempt to process the charge again within 30 days, and I agree to an additional <insert $> charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.  I will not dispute <insert your company name>’s billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.