Monthly Bank Authorization (One Time ACH)

Monthly Bank Authorization (One Time ACH)
- I authorize the LEGACY ACCOUNTING LLC to regularly charge my account for the amount indicated in this form on a regular basis, and shall remain in effect until I request for the cancellation or termination. I also agree to charge $3.00 convinience fee on each recuring transaction.
  
  I likewise certify that I am the authorized signer for this account; that shall be submitted through this form. As long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against the company.
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Email
  example@example.com
- Name(s) on Bank Account (business name if used)
- Routing Number
  must be 9 numbers - no spaces
- Account Number
  must be 9-12 numbers - no spaces
- Bank Name
- Bank Branch
  City, State
- Type of Bank Account
- Date
  
  MonthDayYear
  Date
- Signature
- Enter the message as it's shown
- Should be Empty: