Sample PPD Authorization for Recurring Debits
ACH Recurring Debits Authorization Form < Street Address, City State Zip> < Phone Number>
Please complete the information below: I, ____________________________, authorize to charge my bank account indicated below on the ________ of each for payment of my . I agree that ACH Entries I authorize comply with all applicable laws. Billing Address ____________________________ City, State, Zip Code________________ Phone #__________________________ Email ____________________________ Account Type: Checking Savings Acct Owner Name ________________________ __________________________________ Financial Institution Name _______________________________________________ Account Number _________________ ____ Routing Number _________________________ _ Financial Institution City/State ____________________________________________ I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify of any changes in my account information or termination of this authorization at least XX days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that since this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. I acknowledge that the origination of ACH Entries to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my financial Institution so long as the Entries correspond to the terms indicated in this authorization form. SIGNATURE ______________________________ DATE ______________________
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