Updated June 23, 2023
A recurring ACH payment authorization form authorizes a creditor to deduct recurring payments from a client’s bank account. The payment will be charged at the end of each bill’s cycle or on the recurring dates specified.
Common Uses
- Memberships;
- Subscriptions;
- Payment plans (loan repayments);
- Service contracts; and
- For products being purchased on a repeated basis.
How to Write
Download: PDF, MS Word, OpenDocument
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