Recurring ACH Payment Authorization Form

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The recurring ACH payment authorization form is a document that will authorize a company, landlord, or merchant to deduct recurring payments from a client’s bank account as agreed upon by the parties. The payment will be charged at the end of each bill’s cycle, on the date specified on the form by the account holder. The document will collect information such as personal information that will properly identify the account holder/client, billing information, bank account information, and specific written permission for the merchant to collect payment. Payments will only stop once a purchase has been completed or the account holder stops recurring payments.

How to Write

Step 1 – Download the authorization document – begin by reviewing the information at the top of the document:

  • If the account holder is in agreement, enter the merchant’s name who shall receive permission to collect a one-time payment from the bank account
  • Submit the full name of the account holder
  • Enter the merchant’s name
  • Submit the amount that the account holder will authorize for deduction
  • Enter the date in which the one-time payment may be deducted
  • Provide a description of the good and/or services for which payment shall be deducted on the specified date

Step 2 – Billing Information – Submit:

  • Submit the account holder’s billing address
  • City, State, Zip Code
  • Telephone number
  • Email address

Step 3 – Bank Details – Provide the following information

  • Check the account to be used for the deduction
  • Account name
  • Bank name
  • Account number
  • Routing number

Step 4 – Account Holder’s Final Authorization and Signature

  • The account holder must read the authorization statement at the end of the form
  • Enter an amount agreed upon between the parties, that will be charged, in the event the attempt at deducting the payment, fails
  • Again enter the merchant’s name, allowing permission for them to continue to deduct payment for up to 30 days after the attempt has failed
  • The account holder must then enter their signature
  • Date of signature in mm/dd/yyyy format