Authorize automatic ACH payments for the amount and schedule you choose.
Financial template · 13 fields (12 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your ach payment authorization form
Authorize automatic ACH payments for the amount and schedule you choose.
Use this to record written permission for ACH debits only. Collect the actual payment details through your payment processor's secure setup, not in form fields.
The form separates phone number, mailing address, financial institution name, account type into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
Use this to record written permission for ACH debits only. Collect the actual payment details through your payment processor's secure setup, not in form fields.
Customize the phone number and mailing address questions to match your records and terminology.
Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.
Every field, explained
Account holder name (Name, required)
Email address (Email, required)
Phone number (Phone, required)
Mailing address (Address, required)
Financial institution name (Short text, required)
Account type (Single choice, required)
Debit amount (USD) (Number, required) — For recurring debits, enter the amount per payment.
Debit frequency (Single choice, required)
First debit date (Date, required)
Last debit date (optional) (Date) — Leave blank if payments continue until you cancel in writing.
What the payments are for (Short text, required)
Signature (Signature, required)
Confirmation (Multiple choice, required)
Frequently asked questions
What does this ach payment authorization form template collect?
Alongside contact details, it asks for phone number, mailing address, financial institution name, account type, debit amount (usd), debit frequency, first debit date, last debit date (optional), what the payments are for, signature, confirmation. You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this ach payment authorization form form?
Use this to record written permission for ACH debits only. Collect the actual payment details through your payment processor's secure setup, not in form fields.
Can I customize the acknowledgment and signature fields?
Yes. Provide your complete reviewed instructions or terms before collecting signatures. The signature field records input; it does not verify identity or guarantee legal effect. You can edit the form and print a copy.