Authorization for Direct Payment via ACH
(ACH Debit)
Payer's Name
First
Middle
Last
Payer's Email
example@example.com
The account to be debited:
Checking or Savings Account
Account Type
Bank Name
Ex: Chase, Wells Fargo, Etc.
Account Number
Routing Number
Not to be exceeded amount
(for recurring payments)
Frequency
(for recurring payments)
Start Date (for recurring payments)
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
Year
Consent
I (we) understand that this authorization will remain in full force and effect until I (we) notify COMPANY in writing that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least ten days prior notice in order to cancel this authorization.
YES
Rapid Borrow LLC
1 Stair Way Monroe NY 10950
applications@rapidborrow.solutions
www.rapidborrow.solutions
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