Sample ach authorization form

BANK ACH AUTHORIZATION

Customer hereby authorizes [VENDOR] or its designee successor or assign (hereinafter “Vendor”) to withdraw any amounts including any and all

sales, use and property taxes now due or hereinafter imposed owed by Customer under this [GENERIC AGREEMENT] (“Agreement”) by initiating

debit entries to Customer’s account at the financial institution (hereinafter “Bank”) indicated in this agreement or at any such other Bank as

Customer may from time to time use. In the event of default of Customer’s obligation hereunder, Customer authorizes debit of Customer’s

account or credit card for the full amount due under this Agreement or any portion thereof. Further, Customer authorizes Bank to accept and to

charge any debit entries initiated by Vendor to Customer’s account. In the event that Vendor withdraws erroneously from Customer’s account,

Customer authorizes Vendor to credit Customer’s account for the amount erroneously withdrawn. Customer understands that the foregoing ACH

authorization is a fundamental condition to induce Vendor to accept this Agreement. Consequently, such authorization is intended to be

irrevocable and if cancelled, Customer authorizes Bank to pay a single and final ACH debit to Vendor equal to any balance due on Agreement. In the

event that Vendor is unable to collect any ACH debit to Customer, in its sole discretion, may either deem such an event as default in accordance

with the Agreement or may invoice Customer for payments due under this Agreement and include a $5.00 processing fee in such invoices.

Additionally invoices not paid within 30 days of invoice date will be subject to a 1.5% per month finance charge beginning 31 days after invoice

date.

Bank Name:

Bank Phone Number:

Bank Account Number (not to exceed 17 digits):

Type of Account:

Savings

Checking

Bank Routing and Transit Number (required 9 digits):

Requested Effective Date (optional):

Print Name:

Phone Number:

Authorized Signature:

Date Signed:

Reason for Payment:

Amount:

Frequency of Payment:

GUARANTEE

To induce Vendor to enter into this Agreement for Customer knowing that Vendor is relying on this Guaranty as a precondition to making this

Agreement, I INDIVIDUALLY, PERSONALLY, ABSOLUTELY AND UNCONDITIONALLY GUARANTY to Vendor (and any person or firm Vendor may

transfer its interests to) all payments and other obligations owed by Customer to Vendor under this Agreement and any add-on Services,

Equipment Schedules and future Agreements between Vendor and Customer, including, but not limited to, Vendor’s attorney’s fees and legal costs

incurred in enforcing this Agreement. I will also pay all reasonable costs and fees incurred by Vendor in enforcing this Guaranty. I waive notice of

demand and notice of default and I agree that Vendor may proceed directly against me without first proceeding against Customer or the security

(including the Equipment). This Guaranty shall be governed by the laws of [STATE]. I FREELY CONSENT TO PERSONAL JURISDICTION IN THE [STATE]

COURTS INCLUDING WITHOUT LIMITATIONS THE CIVIL COURT OF THE CITY OF [CITY] AND I WAIVE TRIAL BY JURY. This Guaranty will bind my heirs,

representatives and successors.

Print Name:

SSN:

Authorized Signature:

Date Signed:

ATTACH VOIDED CHECK HERE

A voided check from your checking account must be included in this application

(Do not use a deposit ticket or temporary check)

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Sample ach authorization form
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Sample ach authorization form

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