ACH Authorization Form

ACH Authorization Form

Debit Authorization

for Direct Payment VIA ACH
Customer Information*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Payment Information*

Financial Institution Name

Bank Routing Number

Account NumberConfirm Account Number
Account Type
In accordance with the Sales Agreement we have made, I hereby authorize Habegger Furniture to electronically debit my (our) account (and if necessary, electronically credit my (our) account to correct erroneous debits) as follows:

The agreed-upon down payment will be debited on the date of sale, and the remaining balance will be debited on the day your furniture is delivered.

I authorize Habegger Furniture to initiate future ACH debit entries to my account on an as-needed basis when I request a payment, without requiring a new written authorization for each transaction. I understand that I may authorize individual ACH payments through the following methods: phone, email, text message, or in person.

This authorization will remain in effect until I notify Habegger Furniture that I would like to stop or change it.
Sale Information*

Invoice Number

Sale Total

Today's PaymentRemaining Balance

Postal / Zip Code
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: