ACH Authorization Form - Operating Account

Authorization Agreement for Preauthorized Payments (ACH)
Name(s)*

First NameLast Name
Email*
Phone*
Format: (000) 000-0000.
Add (new participant)Change (financial institution and/or account #Delete (cancel participation)
Fixed Amount and Date Authorization

I/we authorize SAFEchild to debit the financial institution and account number designated above. I/we also authorize SAFEchild to obtain information from the financial institution pertaining to this form, and to credit my/our account if payment is debited in error.

I/we recognize that if I/we fail to provide complete or accurate information on this form, the processing of this form may be delayed and/or my/our preauthorized debit may be erroneously transferred. In the event that funds are erroneously transferred due to my/our failure to provide complete or accurate information on this form, I/we hereby hold SAFEchild harmless for the recovery of such erroneous transfers, notwithstanding any reasonable attempts made by SAFEchild to correct such errors.

I/we understand that should the regularly scheduled debit date fall on a weekend or federal holiday, the debit will occur on the following banking date.
CheckingSavings
Financial institution*
Bank routing # (double-check to ensure you enter the number correctly!) *
Your checking or savings account # (double-check to ensure you enter the number correctly!) *
1st of month15th of month
Debit amount per month:
$*
This authority is to remain in full force and effect until I (or either of us) notify SAFEchild in writing to cancel it in such a time and manner as to afford SAFEchild and the financial institution a reasonable opportunity to act on it.
Your address*

Street address

Street Address Line 2

CityState

Zip code
Signature #1*

Clear
Signature #2

Clear
Should be Empty:

Authorization Agreement for Preauthorized Payments (ACH)