ACH Payment Application

ACH PAYMENT APPLICATION

Originator / Applicant Information

Entity Type: Individual Corporation LLC Partnership Other

Bank Account Information

Voided check or deposit slip attached:

ACH Authorization & Transaction Details

By signing below the Applicant authorizes the payee specified by this application (Originator) to initiate Automated Clearing House (ACH) entries to the bank account specified above and, if necessary, to initiate adjustments for any entries in error. This authorization remains in effect until revoked in writing by the Applicant and until the Originator has had a reasonable opportunity to act on such revocation.

Transaction Type: ACH Debit (Originator debits account) ACH Credit (Originator credits account)

Payment Frequency: One-time Recurring   If recurring, frequency: Weekly Biweekly Monthly Quarterly

Processing, Returns, and Fees

Originator will submit ACH entries in accordance with applicable operating rules. Applicant understands that ACH entries are subject to the rules of the ACH network and that settlement may be final and irrevocable. Applicant agrees to promptly notify the Originator of any changes to the account information. Returned or unauthorized entries may be subject to return-item fees and corrective action as permitted by applicable law.

Representations, Warranties, and Indemnity

Applicant represents and warrants that it is authorized to execute this application and to provide the bank account information above; that the bank account is a valid account in good standing; and that all information provided is true and accurate. Applicant agrees to indemnify and hold harmless the Originator, its agents and processor(s) from any loss, claim, liability or expense (including attorney fees) arising from false information, unauthorized entries, or Applicant's failure to comply with applicable rules.

Bank Verification Consent

Applicant authorizes the Originator and its agent(s) to verify banking information by initiating micro-deposits or other verification entries to the account listed above and to request validation from the bank. Applicant consents to any debit or credit made for verification and acknowledges that verification may include entries returned or charged as a result of incorrect account information.

Permission to perform bank verification: Yes No

Privacy, Security & Data Handling

Applicant acknowledges that account and routing information are sensitive data and agrees that the Originator may store and transmit such data as necessary for ACH processing in accordance with applicable law and industry security standards. Applicant authorizes disclosure of account information to third-party processors for the purpose of establishing and processing ACH transactions.

Additional Terms, Notes, and Special Instructions

Consent to Electronic Authorization and Signature: Applicant consents to receive and execute authorizations electronically and agrees that an electronic signature has the same force and effect as a handwritten signature.

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