Sample Check Draft Authorization Form

The following should serve as an example legal document between you and your client for processing draft checks.

SAMPLE Check Draft Authorization Form

I, CLIENT NAME, authorize YOUR COMPANY NAME to initiate funds from the checking account indicated below. I also authorize my depository financial institution to honor these transfers.

Please Check One Box (required)

		This authorization is valid for this transaction only.  The transaction amount will be $ _______________.          (transaction amount required)
		This authorization is valid for [yearly]   [quarterly]   [monthly]   [weekly] (circle one) transactions. The transaction amount will be $ _______________ .         (transaction amount required)
		This is an open authorization to allow debits to my account for amounts which will vary per transaction based on the order amount.

I have read and agree to all of the terms and conditions on this page and any other contract or document that accompanies this agreement. I certify that I am the authorized account holder for this checking account. I understand this is a binding agreement and I will receive a copy of each check draft in my statement when the item has cleared.

I understand this is a legal binding agreement between COMPANY NAME and CLIENT NAME.

I understand that all returned checks are subject to a $25.00 NSF Fee. This agreement will remain in effect until COMPANY NAME receives my written notice of cancellation via mail, fax or email.

DISCLAIMER:  This is a sample check draft authorization form provided only as a guide. You are required to modify this to meet your specific company requirements and legal needs.  Intellisoft Solutions is not responsible for any issues that may arise between you, your clients, and/or financial institutions.