This document authorizes a company to automatically deduct money from an account of
a third party as set forth in the form for a one time occurrence only. The form can be
used by companies utilizing automatic debit for payment or for an individual desiring to
permit a company to make one debit from the account. It can be revised to permit an
individual to deduct money from an account rather than a company. This document can
be used by parties who wish to allow another party to deduct money from their account
for one time only.
Bank Account Debit Authorization-Single Occurrence
I (we) hereby authorize _____ [Instruction: Insert company name.] (including for
purposes of this authorization its successors and assigns) (“Company”), to initiate an
electronic debit entry to the account (“Account”) and depository financial institution
named below (“Bank”). This form authorizes the Bank holding the account to post such
entry. If the item authorized hereunder is returned unpaid, I authorize an additional
returned check fee of the maximum amount as allowed by the state to be charged to this
account.
If the date on which the scheduled electronic debit entry is a state or federal
holiday or weekend day, I understand such scheduled electronic debit entry will
take place on the next business day. I further authorize Company to return
money that was withdrawn from my account in error by electronically adjusting
my account. I understand I will be notified by Company within a reasonable
time if any such adjustment is made.
I hereby agree to comply with National Automated Clearing House Rules and
Regulations about electronic transfers as they exist on the date of my signature on this
form or as subsequently adopted, amended, or repealed. Applicable state law governs
electronic fund transactions authorized by this agreement in all respects except as
otherwise superseded by federal law.
I hereby further understand, acknowledge and agree that Company may, in its sole
discretion, and for up to seventy-two (72) hours prior to the date for the scheduled
electronic debit entry set forth herein, place a hold on the Account for pre-authorization
purposes (“Pre-Authorization”). Such Pre-Authorization shall not exceed $_____
[Instruction: Insert maximum dollar amount of pre-authorization hold.]. Such
money shall remain my property at all times, except upon failure to fund the scheduled
electronic debit entry set forth herein, and Company shall bear no liability for income
taxes upon such money, except as otherwise required by applicable statute. Upon
payment through the scheduled electronic debit set forth herein, such Pre-Authorization
shall be released, and Company shall have no further claim to such money. I
understand, acknowledge and agree that any overdraft or other fees incurred by me as a
result of any overdraft due to such Pre-Authorization shall be my sole responsibility at
my sole cost and expense. I further understand, acknowledge and agree that my debit
card, if any, may be declined for additional purchases during the term of such Pre-
Authorization as a result of a lower available balance due to the hold on any such funds,
and any overdraft or other fees incurred by me as a result of same shall be my sole
responsibility, at my sole cost and expense.
This authority shall remain in effect only until the date set forth on this Authorization. I
understand I may revoke this authority at any time prior to the date set forth herein for
such scheduled electronic debit by providing notification from me of its termination in
such time and in such manner as to afford Company and Bank a reasonable opportunity
to act on it. If such notification is not provided within such reasonable time, I
understand, acknowledge and agree the Bank may make such scheduled electronic debit,
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and that Company has the right to retain such moneys, subject to my right to dispute
same with Company according to Company dispute procedures, and Bank will have no
further liability with respect to payment of such scheduled electronic debit. If I choose to
terminate this authorization to debit my account, I will notify Bank in accordance with
my agreement with Bank.
NAME: _______________________________________________________________
(as it reads on bank account)
Bank Name: ___________________________________________
City/State: ______________
Bank ABA#: ____________________________
Bank Account #: ________________________
Account Type: __ Checking __ Savings
Bank Phone #(____) _____________________
Bank Accountholder’s
Signature:___________________________________________________
Printed Name:
_________________________________________________________________
Date: __________________________
Date of Debit: _______________________
Amount of Debit: _______________________
[Note: Optional:] In addition to my required minimum payment, please deduct the
following additional amount: $________________________
© Copyright 2012 Docstoc Inc. 3
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