One-Time Authorization for Direct Payment to Sunesis via ACH Debit

One-Time Authorization for Direct Payment via ACH Debit

Just like sending us a check, with far less trouble. The information provided here is no different than that which is provided on any check that you use to pay your bills! Questions? Call us directly at 818/522-5684.
rick@sunesispartners.com
example@example.com
Your Name

First NameLast Name
Your Email Address (we will send you a receipt at this email address)
example@example.com
Your Business Address

Street Address

Street Address Line 2 (if any)

CityState / Province

Postal / Zip Code
Payment is for:
If payment is for specific invoices, please enter those invoice numbers here.
6-digit invoice number(s), separated by commas
Total amount to be debited from your account in dollars and cents.
Financial Institution Name
Financial Institution ABA Routing Number
See example below ( All routing numbers are 9 digits)
Your Account Number
See below for example
Checking or Savings?
Name in which account is held
I authorize Sunesis Partners, Inc., dba R Leonard CSR, upon receipt of this form, to debit the account indicated above for the amount shown and certify that I am empowered to make such authorization.

I understand that because this is an electronic transaction, these funds may be withdrawn from my account immediately upon receipt by Sunesis Partners, Inc. dba R Leonard CSR. If the payment is rejected for Non-Sufficient Funds (NSF), I understand that the Merchant may, at its discretion, attempt to process the charge again within thirty (30) days. I agree to an additional $35 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the Merchant so long as the transaction corresponds to the terms indicated in this agreement.
Account Holder Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

One-Time Authorization for Direct Payment via ACH Debit