ACH Form 2026

Comfort Home Care

Client Intake Form
ACH Authorization

Comfort Home Care uses ACH bank transfer for monthly invoice payments. Please provide your bank account information below. Your account will be debited on or after the invoice due date each month. This authorization remains in effect until revoked in writing
ACH - Account Holder Name
ACH - Bank / Institution Name
ACH - Account Number
ACH - Confirm Account Number
ACH - Account Type
ACH - Routing Number
ACH Authorization - Account Holder Name (printed)
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PAYMENT TIMING

Monthly invoices are issued by Comfort Home Care and are due within 15 days of the invoice date. ACH withdrawals will be processed on or after the invoice due date. Returned payments, insufficient funds, or declined transactions may result in a $25.00 returned payment fee, service suspension, or termination of services.

ACH AUTHORIZATION SIGNATURE

I hereby authorize Comfort Home Care to initiate recurring ACH debit entries to the bank account listed above for payment of monthly invoices for non-medical personal care services. This authorization will remain in effect until I provide written notice of cancellation to Comfort Home Care. To cancel autopay, contact us at 208-681-5533 or info@comforthomecare.org.
ACH Authorization - Signature
ACH Authorization - Date

MonthDayYear
Date
ACH Authorization - Relationship to Client
Should be Empty:

Comfort Home Care