One-time ACH authorization form
Make a one-time ACH authorization form for a single payment, then download it. No signup. This site does not upload what you type.
1Your business
Paying someone instead? Use the vendor ACH form for suppliers or the direct deposit form for employees. To give a client your bank details, use the ACH information form.
2Payment details
3Form options
4Download
Copies the authorization paragraphs as plain text, for a contract or an online sign-up page. They point to the payment details, the bank account and the date on the form, so show those next to them. Check with your bank before use. Using the wording online or by phone
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One-time ACH authorization, US LetterOne-Time ACH Payment Authorization
Use this form to let ____________________ collect a single payment from your bank account by ACH. Fill in each section, sign, and return the form to us.
Account holder
Bank account
Please attach a voided check, or a bank letter that shows the routing and account numbers.
Payment
Authorization
I authorize ____________________ to collect one payment from the bank account named on this form by ACH debit (an electronic withdrawal). This authorization is for a single payment only. The amount and the payment date are shown under "Payment" above. If the payment date falls on a weekend or bank holiday, the payment will be collected on the next business day. ____________________ may also credit the account to correct a payment collected in error.
To cancel this authorization, I must tell ____________________ in writing, at least 3 business days before the payment date.
I confirm that I own this bank account or am authorized to sign for it, and that the details on this form are correct. If this is a business account, the account holder agrees to be bound by the Nacha Operating Rules for this payment. ____________________ will give me a copy of this authorization to keep.
Free. No signup. This site does not upload your details.
How to use this one-time ACH authorization form
- Add your business details. The authorization names your business as the one allowed to take the payment.
- Enter the amount. Type a set amount, or choose “the amount on an invoice” and the form prints a line for the invoice number.
- Enter the date. Pick “on” a set date or “on or after” a date. Leave it empty to print a blank line. Add extra lines, such as a customer number, under Form options.
- Download and send. The customer adds their bank details, signs and dates the form, and returns it.
- Give the customer a copy and keep the signed form.
What a one-time authorization must include
| Element | On this form | Source |
|---|---|---|
| Says it is for a single payment | The title and the sentence “This authorization is for a single payment only” | Nacha |
| The amount | “Payment amount” under Payment | Nacha |
| The timing | “Payment date” | Nacha |
| The customer’s name | The Account holder section | Nacha |
| The account to be debited | The Bank account section | Nacha |
| How to cancel | The “To cancel” sentence with the notice period | Nacha |
| Signature and date of authorization | The signature row | Nacha |
The Nacha link opens Nacha’s page about its standards for authorizations. That page says every consumer debit authorization must hold a minimum set of details, and must be in writing and signed or similarly authenticated. It does not print the list. The list is in the Nacha Operating Rules.
Other sentences on the form, and why they are there:
- Weekend and holiday sentence: ACH payments settle only on banking days. See how long an ACH transfer takes. Nacha’s page How ACH payments work lists it as common practice that a bill payment due on a weekend or holiday is collected on the next business day.
- Correction sentence: Common practice, so a payment taken in error can be refunded to the same account. Not a rule.
- Returned payment fee sentence (optional): Regulation E, 12 CFR 1005.3(b)(3), asks for notice, with the amount, before a fee is collected electronically. State law may limit the fee.
- Business account sentence: Nacha’s guide How ACH works says two businesses need an agreement, and both must be bound by the Nacha rules.
Keep the signed form for two years after the authorization ends. Your bank can ask you for it if the customer’s bank questions the payment.
Common mistakes and how to fix them
- Sending the payment on a different date. If the form says “on” a date, send it for that date. If you need flexibility, choose “on or after”.
- Taking a different amount. The amount on the form is the amount you may take. If it changed, get a new form.
- Splitting one authorization into several payments. One form, one payment. For a payment plan, use the recurring ACH authorization form.
- Trying again and again after a return. A payment returned for insufficient funds may be retried at most two times, within 180 days, and for the same amount. See R01.
Sample one-time ACH authorization form (filled in)
This is what the form looks like once it is filled in. Yours will show your own business name.
One-Time ACH Payment Authorization
Please check the details below, then sign and return this form to Maple Street Fitness.
Account holder
Bank account
Please attach a voided check, or a bank letter that shows the routing and account numbers.
Payment
This payment will appear on your bank statement as: MAPLE ST FITNESS
Authorization
I authorize Maple Street Fitness to collect one payment from the bank account named on this form by ACH debit (an electronic withdrawal). This authorization is for a single payment only. The amount and the payment date are shown under "Payment" above. If the payment date falls on a weekend or bank holiday, the payment will be collected on the next business day. Maple Street Fitness may also credit the account to correct a payment collected in error.
To cancel this authorization, I must tell Maple Street Fitness in writing at [email protected], at least 3 business days before the payment date.
I confirm that I own this bank account or am authorized to sign for it, and that the details on this form are correct. If this is a business account, the account holder agrees to be bound by the Nacha Operating Rules for this payment. Maple Street Fitness will give me a copy of this authorization to keep.
Questions and answers
What is a one-time ACH authorization form?
A one-time ACH payment authorization form is a signed document that lets a business take a single payment from a customer's bank account. It states the amount, the payment date, the account, and how the customer can cancel before the payment is sent.
Can I reuse a one-time ACH authorization for a second payment?
No. It covers one payment only. For a second payment, get a new one-time form, or use a recurring ACH authorization form if you will collect on a schedule.
Can the customer cancel a one-time ACH payment?
Yes, until the notice period on the form runs out. Nacha rules say the right to cancel a single payment scheduled in advance must still leave the business a reasonable chance to act before it sends the payment. The default on this form is at least 3 business days before the payment date.
What does "on or after" a date mean on the form?
It means you may send the payment on that date or any later day. Use it when the exact day depends on when you ship or finish the work. Use a set date when the customer expects the money to leave on one particular day.
Is there a Spanish version of the form?
Yes. Under Form options, tick "Add a Spanish version as page 2". The download then has the English form on page 1 and the same form in Spanish on page 2. The person fills in and signs only one of them.
Sources
- Meaningful Modernization (standards for authorizations), Nacha
- WEB Proof of Authorization Industry Practices, Nacha
- 12 CFR 1005.10, Preauthorized transfers (Regulation E), Consumer Financial Protection Bureau
- 12 CFR 1005.3(b)(3), fees for returned payments (Regulation E), Consumer Financial Protection Bureau
- How ACH payments work (payments due on a weekend or holiday), Nacha
- How ACH works (agreement between two businesses), Nacha
General information, not legal or financial advice. Rules change and banks set their own requirements. Check with your bank before you act. ACH Forms is not affiliated with Nacha.