This document authorizes a company to automatically deduct money from an account of another party as set forth in the form. The form can be used by companies utilizing automatic debit for payment of a debt or a service, or for individuals desiring to permit a company to make scheduled automatic debits from their accounts. This document can be revised to permit an individual to deduct scheduled automatic debits rather than a company. This document should be used by parties who wish to allow another party to deduct money from their account.
This document authorizes a company to automatically deduct money from an account of another party as set forth in the form. The form can be used by companies utilizing automatic debit for payment of a debt or a service, or for individuals desiring to permit a company to make scheduled automatic debits from their accounts. This document can be revised to permit an individual to deduct scheduled automatic debits rather than a company. This document should be used by parties who wish to allow another party to deduct money from their account. Bank Account Debit Authorization-Multiple or Repetitive Occurrences 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 or entries to the account (“Account”) and depository financial institution named below (“Bank”). This form authorizes the Bank holding the account to post all such entries. If any 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 or entries is a state or federal holiday or weekend day, I understand such scheduled electronic debit entry or entries 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 I further authorize Company to return money that was withdrawn from my account in error by electronically adjusting my account.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 adjustments are 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electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended, or repealed.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state law governs electronic fund transactions authorized by this agreement in all respects except as otherwise superseded by federal law. This authority shall remain in effect until Company and Bank have received 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, or until my loan account has been paid in full [Instruction: Delete bolded language if inapplicable.], or until Company or Bank has sent me ten (10) days’ written notice of Company’s or Bank’s termination. If I choose to terminate this authorization to debit my account, I will notify Bank in accordance with my agreement with Bank. If such notification is not provided within such reasonable time, I understand, acknowledge and agree the Bank may make such scheduled electronic debit, 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. [Note: Optional language if debit amounts vary – the below is sample language, and should be revised to reflect the true agreement between the parties with respect to billing.]: I hereby authorize Company to initiate debit entries to the Account indicated below in the amounts equal to each invoice prepared by Company, and I authorize Bank to process said entries. I understand that invoice amounts are variable with each billing period. I elect to be notified of my payment amounts via regular monthly invoicing, to be sent to me via U.S. mail or email. I understand my Services Agreement allows me 15 days upon receipt of any invoice to dispute same. Upon notice of dispute of an invoice, if the dispute cannot be resolved at least 2 days prior to the draft date, the automatic debit will be suspended until the dispute is resolved. Debits will be performed 16-20 days from the date of each invoice. © Copyright 2012 Docstoc Inc. 2 [Note: Optional language if debit amounts may change in future] I hereby understand, acknowledge and agree the minimum required monthly payment due to Company can change due to new loans, future disbursements of current loans, changes in variable interest rate and current loans reverting to repayment. If the minimum required monthly payment changes for any reason, this authorization will be automatically amended to authorize the debit of an amount equal to the new required minimum monthly payment plus any optional additional amount indicated below. I understand such new required minimum monthly payment may be higher or lower than the current payment. 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: __________________________ Frequency of Debit: _____________________ Date of Debit: _______________________ Amount of Debit: _______________________ Number of Debits: ___________________ Final Debit Date: _______________________ [Note: Optional:] In addition to my required minimum payment, please deduct the following additional amount with each debit: $________________________ © Copyright 2012 Docstoc Inc. 3
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