How Do I Obtain an ACH Authorization Form?

Businesses that accept payments via a checking or savings account (i.e. ACH) are required to obtain a signed agreement (ACH Authorization) that grants permission to charge or refund the bank account for a customer or business. The ACH Authorization must be signed prior to the ACH transaction and the signed ACH Authorization must remain on file for at least two years.

An ACH authorization form will typically specify the following:

  • Customer or business name
  • Routing number
  • Account number
  • Amount
  • Transaction type: one-time charge, refund or recurring
  • If recurring, start date and frequency
Please Note: ARC, BOC, POP is not supported and checks are not meant to be converted to PPD / CCD.

ACH Authorization Form Options

Option 1 - Collect Paper Copy of ACH Authorization Form

If you prefer to collect a paper copy of the ACH Authorization Form, we've provided an example ACH authorization form below.

Please note, the ACH form template is intended to be updated for your specific needs.

Example ACH Authorization Form Template

Option 2 - Use PayJunction Receipts to Collect ACH Authorization Form

All PayJunction receipts include the majority of the information that's required for an ACH Authorization Form. We suggest adding additional language in the receipt Disclaimer in order to comply with ACH Authorization Form guidelines. Signature on the ACH receipt can be used as a backup if an ACH Authorization is not obtained.

Instructions to update the Disclaimer on PayJunction receipts:

Example language to be included in the Disclaimer:

I authorize the charge on my account according to the terms indicated in this ACH Authorization Agreement. I agree to notify in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next billing date. I understand that this authorization will remain in effect until I cancel it in writing. I certify that I am an authorized user of this account and will not dispute transactions with my bank; so long as the transactions correspond to the terms indicated herein. 

Why are ACH Authorization Forms Important?

Rules regarding the acceptance of ACH payments are governed by NACHA. Obtaining proper ACH authorization to process an ACH payment will protect your business from disputes. 

Per NACHA rules, here are some additional reasons that a customer can dispute an ACH transaction:

  • The transaction was never authorized by the account owner.
  • The transaction was processed earlier than the date specified on the authorization form.
  • The amount charged is different than the amount that was authorized. However, it is possible to obtain ACH authorization for variable amounts.

If a customer disputes an ACH transaction, and an authorization form was not obtained, then the business could lose the dispute.   

The Electronic Funds Transfer Act adopted as Regulation E by the Federal Reserve Board requires that a consumer be provided a right to stop payment on any of a series of pre-authorized transfers from the consumer’s account. This right applies until the third business day before the settlement date of the transfer.
There is no warranty for the example ACH authorization form provided herein. PayJunction provides access to the example ACH authorization form on this webpage "as is" without warranty of any kind, either expressed or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The entire risk as to the quality and performance of the example ACH authorization form is with you. Should the example ACH authorization form prove defective, you assume the cost of all necessary repair or correction. It is the merchant's responsibility to ensure the example ACH authorization form meets the requirements outlined by NACHA.

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