AUTHORIZATION AND AGREEMENT FOR AUTOMATED CLEARING HOUSE (ACH) DEBITS AND CREDIT
As a duly authorized check signer on the financial institution account identified below, I (we) authorize
(COMPANY) to perform scheduled or periodic electronic funds transfer debits and / or credits from my account
identified below for payments due or when applicable, apply electronic funds transfer credits to the same.
Furthermore, if any such electronic debit(s) should be returned by my (our) financial institution as Non-Sufficient
Funds (NSF), I (we) authorize (Company) to collect a returned item fee of $30.00 per item by electronic debit from
my (our) account identified below. For accounting purposes, all electronic debits will be reflected in the monthly
bank statement that corresponds with the financial institution account identified below.
I understand and authorize all of the above as evidenced by my (our) signature below.
Company Name Signature Date
Financial Institution account “identifying information”:
Financial Institution Name(Bank Name): Bank Service Representative:
Bank Street Address: City/State/Zip:
Bank Phone Number: Bank Fax Number:
ACH Routing / Transit / ABA Number (9 digits) Account Number:
Financial Institution
00001
Date: _________
Pay to the order of _______________________ $
Memo ____________
This is the 9 digit Transit/ABA Bank Routing number � XXXXXXXXX 0000000000 �� The account number i
usually to the ie. right of the Routing number. Some Financial Institutions add the check number between the
Routing and
Account number.
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