Authorize us to collect your payments by automatic direct debit.
Financial template · 13 fields (12 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your ach authorization form for direct debit
Authorize us to collect your payments by automatic direct debit.
This form records the payer's authorization only. Collect full bank details through a secure processor, for example by connecting Stripe and adding a Payment field in the editor, never in plain form fields.
The form separates phone number, billing address, bank name, account type into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
This form records the payer's authorization only. Collect full bank details through a secure processor, for example by connecting Stripe and adding a Payment field in the editor, never in plain form fields.
Customize the phone number and billing 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)
Billing address (Address, required)
Bank name (Short text, required)
Account type (Single choice, required)
Last 4 digits of the account (Short text, required) — For reference only. Full bank details are collected securely.
Amount per debit (USD) (Number, required)
Debit frequency (Dropdown, required)
First debit date (Date, required)
Authorization (Multiple choice, required)
Account holder signature (Signature, required)
Date signed (Date, required)
Frequently asked questions
What does this ach authorization form for direct debit template collect?
Alongside contact details, it asks for phone number, billing address, bank name, account type, last 4 digits of the account, amount per debit (usd), debit frequency, first debit date, authorization, account holder signature, date signed. You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this ach authorization form for direct debit form?
This form records the payer's authorization only. Collect full bank details through a secure processor, for example by connecting Stripe and adding a Payment field in the editor, never in plain 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.