Parties and Authorization Date
Effective Date of Authorization: [[Effective Date]]
Business / Originator Name: [[Business Name]]
Account Holder / Payor Name: [[Business Name]]
Bank Account Information
Bank Name: [[Business Name]] Bank (or payor's bank)
ABA Routing Number: [[Bank Routing Number]]
Account Number: [[Account Number]]
Account Type: [[Account Type]]
The Account Type must be specified as either "checking" or "savings". The Company will use the routing and account numbers exactly as provided for all authorized entries.
Authorization Scope and Payment Details
The undersigned Account Holder authorizes the Company to initiate ACH debit entries for the following:
Authorized Payment Amount: [[Payment Amount]]
Payment Frequency: [[Payment Frequency]]
Effective Date for First Debit: [[Effective Date]]
This Authorization applies to one-time debits and recurring debits as selected. The Company may initiate entries only for amounts and on schedules matching the details above, including any adjustments required for returned items or corrections, subject to required advance notices for variable amounts.
Entry Class Codes and NACHA SEC Context
The Company shall use the appropriate NACHA Standard Entry Class (SEC) code for each entry initiated under this Authorization. The selection depends on the nature of the account and the relationship.
- WEB entries are used for authorizations obtained via the internet or mobile channel where the consumer provides the routing, account number, and account type electronically. WEB entries carry specific authentication and record retention requirements.
- PPD entries are used for consumer (personal) accounts where the Account Holder has provided a written or similarly authenticated authorization in advance. PPD entries are subject to Regulation E consumer protections, including the right to stop payment and receive notice of changes in amount or date for recurring debits.
- CCD entries are used for corporate or business accounts. These entries are primarily governed by UCC Article 4A and applicable NACHA commercial rules. The Company ID and authorization representations differ for business accounts.
The Company represents that it will select and apply the correct SEC code based on the account type and authorization method. Misuse of SEC codes may result in returns, fees, or regulatory scrutiny.
One-Time Versus Recurring Debits
The Account Holder selects one of the following:
- One-time debit only. This Authorization covers a single ACH debit in the amount stated on or after the Effective Date.
- Recurring debits on the schedule specified under Payment Frequency. This Authorization remains in effect for all scheduled debits until revoked in accordance with the revocation terms below.
The Company will not initiate recurring debits beyond the scope authorized. For variable recurring debits, the Company will provide advance notice as required by applicable rules and the underlying agreement.
Revocation of Authorization
The Account Holder may revoke this Authorization at any time. Revocation must be provided in writing and must comply with NACHA requirements.
- Written revocation notice must be delivered to the Company at the address or email on file for [[Business Name]].
- For recurring consumer PPD or WEB debits, the revocation notice must be received by the Company at least three (3) banking days before the next scheduled debit date to be effective for that entry.
- Revocation is effective upon the Company's actual receipt and reasonable processing time, not upon mailing or transmission.
- The Company will cease initiating new entries after the effective revocation date.
- The Account Holder remains fully liable for any amounts due under the underlying agreement or transaction even after revocation of this payment authorization.
- Revocation does not affect entries that have already been initiated or are in process within the ACH network.
The Company shall honor a valid revocation and shall not re-initiate debits after the effective date.
Record Retention and Authorization Records
The Company agrees to maintain a copy of this signed or authenticated Authorization (including electronic records) for a minimum of two (2) years following the later of:
- The date of revocation of this Authorization.
- The date of the last ACH entry initiated under this Authorization.
The Company will provide a copy of the Authorization to the Account Holder upon request and will make records available to the Account Holder's financial institution or regulators as required by NACHA Operating Rules.
Account Holder Representations and Warranties
The Account Holder represents, warrants, and agrees that:
- The Account Holder is the owner of the account or has full legal authority to authorize debits from the designated account.
- All information provided, including the routing number, account number, and account type, is accurate and complete.
- The Account Holder will notify the Company promptly of any change in account ownership, account details, or authority to act.
- The Account Holder understands that ACH entries are irrevocable once initiated except as provided by NACHA rules, Regulation E (for consumer accounts), or the account agreement with the depository bank.
- The Account Holder has received or has the right to receive a copy of this Authorization.
Company Representations
The Company represents that:
- It is authorized to initiate ACH entries for the purpose described.
- It has procedures in place to ensure proper authorization is obtained and retained.
- It will use the Authorization only for the amounts, frequency, and purposes stated.
- It will comply with all NACHA Operating Rules, including requirements for prenotification where applicable, return processing, and error resolution.
Liability and Indemnification
Except to the extent caused by the Company's gross negligence or willful misconduct, the Account Holder is responsible for losses arising from inaccurate account information provided or failure to notify of changes. The Company is responsible for initiating entries only within the scope of this Authorization.
Governing Law and Venue
This Authorization shall be governed by the laws of the United States and the state in which the Company maintains its principal place of business, together with the NACHA Operating Rules as in effect from time to time. Any disputes shall be resolved in the courts of the applicable jurisdiction.
Signature Block
By signing below, the Account Holder authorizes [[Business Name]] to initiate ACH debit entries to the account identified above in the amount and frequency stated, effective on the date shown, and acknowledges that the Account Holder has read, understands, and agrees to the terms of this Authorization, including the revocation procedures and record retention requirements.
Account Holder / Authorized Signer Signature: ________________________________
Printed Name: [[Business Name]]
Title (if signing on behalf of entity): ________________________________
Date: [[Effective Date]]
Account Holder Address (for notices): ________________________________
Account Holder Phone: ________________________________
Account Holder Email: ________________________________
Company Acknowledgment (Optional but Recommended)
The Company acknowledges receipt of this Authorization.
Company Representative Signature: ________________________________
Printed Name: ________________________________
Title: ________________________________
Date: [[Effective Date]]
Company Address for Revocation Notices: ________________________________
Company Phone for ACH Matters: ________________________________
Company Email for ACH Matters: ________________________________
Notary Acknowledgment (If Required by Company Policy or State Law)
State of ________________
County of ________________
On [[Effective Date]], before me, the undersigned notary public, personally appeared the signer identified above, proved to me through satisfactory evidence of identification to be the person whose name is signed on this document, and acknowledged that they signed it voluntarily for the purpose stated herein.
Notary Public Signature: ________________________________
Printed Name of Notary: ________________________________
My Commission Expires: ________________________________
(Place Notary Seal Here)
Schedule of Payments or Additional Instructions (Exhibit A)
Any specific schedule of debit dates, amounts that vary, or special instructions may be attached as Exhibit A and incorporated by reference. In the absence of an attached schedule, the Payment Frequency and Amount stated above govern all entries.
Key Information Summary Table
| Field | Provided Value |
|------------------------|---------------------------------|
| Business Name | [[Business Name]] |
| Bank Routing Number | [[Bank Routing Number]] |
| Account Number | [[Account Number]] |
| Account Type | [[Account Type]] |
| Payment Amount | [[Payment Amount]] |
| Payment Frequency | [[Payment Frequency]] |
| Effective Date | [[Effective Date]] |
Additional Terms
- This Authorization may be executed in counterparts or by electronic signature, each of which shall be deemed an original.
- Any amendment to this Authorization requires a new signed form or written amendment signed by the Account Holder.
- If any provision of this Authorization is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.
- The Account Holder may request a copy of this Authorization at any time by contacting the Company.
Disclaimer
This document is a sample template intended to illustrate a compliant ACH debit authorization form under NACHA Operating Rules for WEB, PPD, and CCD entry classes. It includes required elements such as routing and account fields, account type selection, originator identification, amount and frequency specification, effective date, revocation language requiring at least three banking days' written notice for recurring consumer debits, entry class context, authorization retention for a minimum of two years, and signature blocks.
Actual requirements may vary based on the specific SEC code used, whether the account is consumer or corporate, the policies of the originating and receiving depository financial institutions, and applicable federal and state law. The Company must verify current NACHA Operating Rules, ensure proper registration and setup with its ODFI, and consult qualified legal, compliance, or banking counsel before using this form for live transactions. This template is provided for informational purposes and does not constitute legal, banking, compliance, or financial advice. Information is current as of June 2026.
The Company and Account Holder should retain copies of the executed Authorization and any underlying agreement.
