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.
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 I further authorize Company to return money that was withdrawn from my account in error by electronically adjusting my account.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electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended, or repealed.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state law governs electronic fund transactions authorized by this agreement in all respects except as otherwise superseded by federal law.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, © Copyright 2012 Docstoc Inc. 2 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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