ACH Authorization Form

The ACH form is used in order to authorize entry to the requester’s bank accounts that are maintained by the involved financial institution.

Extracted Text for Proper Search

ACH Authorization Form 	
 
 
 
 	
CREDIT/DEBIT AUTHORIZATION FORM	 	
 
I (we) hereby authorize ___________________________ (THE 	COMPANY) to initiate entries to 	
my (our) checking/savings accounts at the fina	ncial institution listed below (THE FINANCIAL 	
INSTITUTION), and, if necessary, initiate adjustm	ents for any transactions credited/debited in 	
error. This authority will rem	ain in effect 	until THE COMPANY is notified by m	e (us) in writing 	
to cancel it in such tim	e as to afford 	THE COMPANY and THE FINANCIAL INSTITUTION a 	
reasonable opportunity to act on it. 
 
________________________________________________________________________\
_ 
(Nam	e of	 Financial Institution) 	
 
________________________________________________________________________\
_ 
(Address of	 Financial Institution - Branch, City, State, & Zip) 	
 
________________________________________           _____________________\
______ 
(Signature)                                                           \
               (Date) 
 
________________________________________________________________________\
_ 
(Nam	e - PLEASE PRINT) 	
 
________________________________________________________________________\
_ 
(Address - PLEASE PRINT) 
 
Set Am	ount: ___________________  or   Maxim	um Am	ount: _______________________ 	
 
Financial Institution Routing Num	ber:__________________________________________ 	
 
Checking/Savings Account Num	ber:___________________________________________ 	
 
These num	bers are located on the bottom	 of your check as follows: