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