Recurring ACH Payment Authorization Form

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Updated April 20, 2022

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: Adobe 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