One (1) Time ACH Payment Authorization Form

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Updated April 20, 2022

A one (1) time ACH payment authorization form is a document provides permission to a merchant or company to deduct a single payment from the account holder’s bank account. Once the payment has been deducted, the form allowing permission for deduction becomes null and void. The form will allow the account holder to state the date in which the stated company will have the ability to deduct the single payment. The payment will not be deducted before that date.

How to Write

Step 1 – Download the form – Enter the following information:

  • The name of the company who is granted permission to deduct a one time payment from the account holder’s bank account
  • Read the permission statement
  • If the account holder is in agreement they must first enter their full name
  • Enter the name of the merchant who will have permission to charge the account
  • Submit the amount that the merchant has permission to deduct
  • Provide the date in which the merchant has permission to make the deduction
  • Provide a description of the goods and/or services for which the charge will be made

Step 2 – Billing Information – Submit the following:

  • The account holder’s billing address
  • City, State, Zip Code
  • Phone number
  • Email address

Step 3 – Bank Details –

  • Check the box indicating the account to be charged
  • Enter the Account name
  • Bank name
  • Account number
  • Routing number

Step 4 – Statement of Permission –

  • Read the statement
  • In the event the account, when charged, has insufficient funds, enter the name of the merchant allowing them permission to charge the account again within 30 days
  • Enter the amount of the agreed additional charge
  • Submit the name of the merchant again, stating that the account holder will not dispute the charges as long as the charges are correct and charged only one time
  • The account holder must then submit their signature
  • Date the signature in mm/dd/yyyy format