The Pre-Authorized Debit Form is a crucial financial document used in the United States to establish and maintain recurring payment arrangements. It is commonly used when a customer needs to set up automatic payments for services, subscriptions, or regular financial obligations. The form must comply with federal regulations including the Electronic Fund Transfer Act, Regulation E, and NACHA Operating Rules. It typically includes comprehensive account holder information, banking details, specific payment terms, and clear authorization statements. This document is essential for businesses that process recurring payments and provides legal protection for both the paying and receiving parties. Its proper completion and maintenance are critical for ensuring valid payment authorization and regulatory compliance.
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1. Account Holder Information: Complete details of the account holder including full name, address, phone number, and email
2. Financial Institution Details: Information about the bank/financial institution where the account is held, including branch details
3. Bank Account Information: Specific account details including account number, routing number, and account type
4. Payment Authorization: Express authorization for the automatic debits, including purpose of payments and confirmation of account holder's agreement
5. Payment Details: Specific information about the payment amount, frequency, start date, and duration
6. Cancellation Rights: Information about the right to cancel and the process for cancellation
7. Terms and Conditions: General terms including NSF fees, timing of debits, and modification procedures
8. Authorization Signature: Space for date and signature of account holder(s)
1. Joint Account Authorization: Additional section required when the bank account is jointly held, requiring all account holders' authorization
2. Variable Payment Authorization: Required when payment amounts may vary, including maximum amount and notification requirements
3. Electronic Communication Consent: Optional section for authorizing electronic communications and notices
4. Business Account Details: Required when the account holder is a business, including business registration information and authorized signatories
1. Schedule A - Payment Schedule: Detailed breakdown of payment dates, amounts, and frequency if payments are varying or complex
2. Schedule B - Void Check: Attachment of a void check or bank documentation to verify account information
3. Appendix 1 - Terms and Conditions: Detailed terms and conditions if too lengthy to include in main form
4. Appendix 2 - Cancellation Form: Optional pre-formatted form for future cancellation of the pre-authorized debits
Authors
Relevant legal definitions
Clauses
Relevant Industries
Banking and Financial Services
Insurance
Utilities
Telecommunications
Subscription Services
Property Management
Healthcare
Education
Non-profit Organizations
Professional Services
Retail
Technology Services
Relevant Teams
Finance
Accounts Receivable
Legal
Compliance
Customer Service
Operations
Treasury
Payment Processing
Collections
Banking Relations
Relevant Roles
Financial Manager
Accounts Receivable Manager
Billing Coordinator
Payment Operations Specialist
Compliance Officer
Legal Counsel
Customer Service Manager
Account Manager
Treasury Manager
Payment Processing Specialist
Finance Director
Banking Relations Manager
Collections Specialist
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