Provider ACH Payment Authorization

This form is used for Automated Clearing House (ACH) payments. The information being collected on this form will be used by Emotional Relief Fund to transmit payment data, by electronic means, to your checking/savings account with your financial institution. I authorize Emotional Relief Fund to make payments to my bank account indicated below:

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Emotional Relief Fund in writing of any changes in my account information or termination of this authorization effective upon submission of an invoice for payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.