1-Time ACH Payment Authorization Form

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The 1-time ACH authorization form is a document used to provide permission to a company or person to perform a one (1) time debit transfer from an account holder’s checking or savings account. The most common use of an ACH (Automated Clearing House) payment is a one-time bill payment; however, the below form can be used for a variety of purposes. Due to the function of this particular ACH authorization form, once the account holder has been debited, the document will become null and void. This payment method is often favored over the employment of a credit card or paper check as it is cost effective and considerably more efficient..How to Write

Step 1 – Start off by downloading the document in Adobe PDF and open it up in the PDF viewer of your choice.


Step 2 – Under the “Customer Information” heading, enter your full name.

Step 3 – Information pertaining to the debit account must be included next. The following info is required:

  • Financial Institution Name
  • Account Number
  • Routing Number
  • Account Type (Checking or Savings)
  • Account Classification (Consumer or Business)
  • Amount of Authorized Debit

Step 4 – Beneath the “Customer Authorization” heading, enter the name of the individual to whom you’re giving the authority to perform the transaction. Provide the date, print the form, and sign the document.