ACH Authorization Form Template

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Updated Apr 24, 2025
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An ACH Authorization Form is a financial agreement between a payor and a payee that permits electronic transfers directly between bank accounts. It is used by businesses and customers to enable automatic payments, reduce paperwork, and avoid missed or late transactions.

 

 

ACH AUTHORIZATION FORM

Name:  

Address:  

 

Bank name:  

Bank routing number:  
Account number:  
Type of account:  

I, the undersigned, hereby authorize   to initiate one-time electronic funds transfer (ACH transaction) of   from the specified bank account for the purpose of  .

By signing below, I acknowledge and agree to the following terms and conditions:

1. I understand that this authorization is effective as of   and will remain in effect until I provide written notification of its cancellation to   to   .

2. I authorize   to initiate ACH transaction in accordance with the agreed-upon terms.

3. I am responsible for ensuring sufficient funds are available in the designated bank account to cover the authorized transaction.

4. I understand that it may take a certain amount of time for the ACH transaction to be processed, and I release   from any liability for any delay or error in the transfer of funds.

5. I understand that I have the right to revoke this authorization at any time. To do so, I will provide written notice to   at least   days before the scheduled debit date.

6. I have read and understood the terms and conditions outlined in this ACH Authorization Form.

By signing below, I authorize   to initiate ACH transaction from the specified bank account as indicated above.

Signature: ____________________________  

Date:  

Written by Karyna Pukaniuk - Reviewed by Jonathan McGill

Template Types

Direct Deposit Authorization Form
This form allows an employee to authorize automatic payments directly into their bank account.

Template Description

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Paper titled "ACH Authorization Form", man typing on a laptop

An ACH authorization form template will help you quickly create a clear, legally sound document without needing any legal expertise. The ACH form PDF is easy to fill out online, guides you through every step, and includes all the key parts — like bank info, transaction amount, and consent terms — so you don’t miss anything important.

When To Use an ACH Payment Form Template

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You can use an ACH payment authorization form PDF when you want to set up automatic payments or deposits between bank accounts. It’s helpful in these situations:

  • You're paying rent or a loan on a regular basis;
  • You're a business collecting payments from customers automatically;
  • You're an employee setting up direct deposit for your paycheck;
  • You're giving someone permission to withdraw funds from your account (like for a gym membership or subscription).

How To Fill Out an ACH Authorization Form

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1. Fill in your personal and bank details

blank ACH authorization form

Start by entering your full name and address in the printable blank ACH authorization form template. Then, add the banking information that will be used for the transfer:

Example:
  • Name: John Doe
  • Address: 123 Maple Street, Springfield, IL 62704
  • Bank name: Chase Bank
  • Bank routing number: 123456789
  • Account number: 000987654321
  • Type of account: Checking

2. Write the authorization statement

sample ACH authorization form

This part of the blank ACH form is where you allow a company or person to take money from your bank account.

Example:

I, the undersigned, hereby authorize [Sunrise Utilities] to initiate one-time electronic funds transfer (ACH transaction) of [$120.00] from the specified bank account for the purpose of [monthly utility bill payment].

3. Terms of the blank ACH authorization form template

free ACH payment authorization form

Read through the five standard terms. You’ll fill in the blanks with the correct dates or names.

Example:
  1. I understand that this authorization is effective as of April 30, 2025 and will remain in effect until I provide written notification of its cancellation to Sunrise Utilities to [email protected].
  2. I authorize Sunrise Utilities to initiate ACH transaction in accordance with the agreed-upon terms.
  3. I am responsible for ensuring sufficient funds are available in the designated bank account to cover the authorized transaction.
  4. I understand that it may take a certain amount of time for the ACH transaction to be processed, and I release Sunrise Utilities from any liability for any delay or error in the transfer of funds.
  5. I understand that I have the right to revoke this authorization at any time. To do so, I will provide written notice to Sunrise Utilities at least 5 days before the scheduled debit date.
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