ACH Information Collection Form
ACH Information Collection Form
Client Information:
- Full Name:
- Company Name (if applicable):
- Email Address:
- Phone Number:
Bank Account Information:
- Bank Name:
- Routing Number:
- Account Number:
- Account Type (Checking/Savings):
- Name on the Bank Account:
Authorization: I, [Client's Full Name], authorize [Your Company Name] to initiate debit entries to my account indicated above at the depository financial institution. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authorization will remain in full force and effect until [Your Company Name] has received written notification from me of its termination in such time and in such a manner as to afford [Your Company Name] and the depository financial institution a reasonable opportunity to act on it. I agree to promptly notify [Your Company Name] in writing of any changes to my account information.