Monthly Auto Payment - ACH Client Authorization Form

Monthly Auto Payment - ACH Client Authorization Form

For invoices billed out at the end of each month.
Business Name*
Phone Number*
Format: (000) 000-0000.
Contact Name*

First NameLast Name
Email*
Billing Address*

Street Address

Street Address

CityState

Zip Code
Name on Bank Account*
Bank Name*
Checking or Savings*
Routing Number*
Account Number*
Signature*
Date*
Title*
Terms and Conditions: I understand and agree that any and all changes in my account information, including requests to terminate this agreement, must be in writing and be delivered to Sawyer Accounting Services, LLC, at least 15 days prior to the next due date. If the payment due date falls on a weekend or holiday, I understand and agree that the payment may be executed on the next business day. I understand and agree that as this is an electronic transaction, adequate funds must be available for withdrawal from my account by the payment due date. In the case of an ACH transaction being rejected for Non Sufficient Funds (NSF), submission error, or other bank related return reasons I understand and agree that the company may at its discretion resubmit the ACH debit transaction within thirty (30) days. I understand and agree that, in accordance with the signed contract, a 20% late charge will be assessed if the amount due is not received in good and collected funds by the end of the grace period (60 days). I also understand and agree that a return item charge may be assessed for each returned ACH debit. I acknowledge that the origination of ACH transactions to my account must comply with provisions of U.S. law and agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form. *
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