ACH Payment Written Authorization (WEB/TEL/PPD/CCD)

When you accept ACH payments, NACHA requires that you receive consent (authorization) from your customer to debit their bank account. In the event of an ACH Return, the customer's bank may ask you to share the proof of your customer's authorization. You must store your proof of customer authorization for two years after the transaction.

A written authorization is acceptable for many ACH transactions, including recurring transactions.

Additionally, when an ACH transaction is Returned for Not Authorized, Qualpay requires you to obtain a new written authorization from your customer before you can debit their bank account again.

Use the below text to obtain your customer’s consent.


<Customer Address >
<City, State, Zip>

Electronic Funds Transfer Payment Authorization 

Please allow this letter to confirm that by your signature below, you hereby authorize <BUSINESS NAME> to debit your account ending in  <XXXX> (show the last 4 digits of the account number) electronically for amounts due and owing between <BUSINESS NAME> and <CUSTOMER NAME>. 

This authorization shall remain in place unless and until revoked by <CUSTOMER NAME> via a written directive to <BUSINESS NAME>, at least five (5) days before any date in which any electronic funds transfer is to occur, to permit <BUSINESS NAME> sufficient time to act on it. 

<BUSINESS NAME> agrees that it shall provide an invoice to <CUSTOMER NAME> indicating the amount(s)  due, together with the specific date that <CUSTOMER NAME's> account shall be electronically debited.  

In the unlikely event your payment is returned unpaid, we may elect to electronically (or by paper draft)  re-present your payment up to two more times. You also understand and agree and authorize or permit <BUSINESS NAME> to collect a return processing charge by the same means, in an amount not to exceed that as permitted by state law. 

If you have any questions concerning this payment transaction, please contact us at <Business phone number> during our normal business hours, < 8:00 AM to 5:00 PM>. 

As and for <CUSTOMER NAME>, authorization is hereby granted to <BUSINESS NAME> to electronically debit our bank account noted below for amounts owing to <BUSINESS NAME>.

Type of Account (mark one): [ ] Checking Account [ ] Savings Account

Bank Name: ________________________________________ 

Routing Number:____________________________ Account Number:____________________________

Payment Schedule (as checked): 

[ ] Single One-Time Transaction 

Amount:  $_______________

Date: ____________________ 

[ ] Recurring Transactions

Amount: $________________  

Beginning Date: ____________________ 

Number of payments: ____________________

[ ] Weekly
[ ] Monthly
[ ] Other ______________________________

You acknowledge receiving a copy of this authorization when you signed it. 


Customer Signature Date: ____________

Very truly yours,