Consumer Authorization for Direct Payment via ACH

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ACH Authorization

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.

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Change Information

I (we) authorize H-Authentica Inc. (“COMPANY”) to electronically debit my (our) account and, if necessary, to electronically credit my (our) account to correct erroneous debits as follows:

Checking Account

Savings Account

at the depository Financial Institution named below (“DEPOSITORY”).

I (we) agree that ACH transactions I (we) authorize comply with the laws of the United States and all applicable law.

First Name

Last Name

Routing number:

Account number:

Name(s) on the account:

Debit transaction frequency:

Single Entry (one-time payment)

Recurring Entries (entries that recur at substantially regular intervals, without further affirmative action by the Receiver)

Date of debit (if Single Entry) or date of first debit:

Number of and/or frequency of debits:

Authorized debit amount:

I (we) understand that this authorization will remain in full force and effect until I (we) notify COMPANY in writing that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least 15 days prior notice in order to cancel this authorization.

Name(s):

Date:

Signature

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Consumer Authorization for Direct Payment via ACH

Your Gateway to Luxury

ACH Authorization

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Consumer Authorization for Direct Payment via ACH

Your Gateway to Luxury

ACH Authorization

About H-Authentica

Our Services

Quick Links

Newsletter Subscription

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