Sample PPD Authorization for ACH Credits
ACH Credit Authorization Form < Street Address, City State Zip> < Phone Number>
Please complete the information below: I, ____________________________, authorize to initiate ACH credits to my account information below until such time when my authorization is revoked. In addition, I also authorize to debit my account to correct erroneous credits that are received in error. 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 receipt of payment. I acknowledge that the origination of ACH Entries to my account must comply with the provisions of U.S. law.
SIGNATURE ____________________________ DATE ______________________
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