ACH Authorization Form

Recurring Payment Plan Authorization Form Checking/Savings Account
Schedule your payment to be automatically deducted from your checking or savings account.

The Recurring Payment Plan will help you in several ways:
- It's convenient (saving you time and postage)
- Your payment is always on time (even if you're out of town), elminating late charges
- It's easy to sign up
Here's how the Recurring Payment Plan works:

You authorize regularly scheduled charges to your checking/savings account. You will be charged each billing period the total amount due for that period. A receipt of payment will be emailed to you and will appear on your statement.
Name*
Rockingham Cooperative Account Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Account Type*

CheckingSavings
Name on Account*
Bank Name*
Bank Routing Number (9 Digits)*
Bank Account Number*
Bank City/State*
Please indicate the date to begin deductions*

MonthDayYear
Date
Please choose ONE of the two options below:*

I authorize Rockingham Cooperative, Inc. to charge/debit my account on or about the 15th of each month and will take advantage of any term discounts offered for payment of my bill.I authorize Rockingham Cooperative, Inc. to charge/debit my account on or about the LAST BUSINESS DAY of each month and will NOT take advantage of any term discounts offered for payment of my bill.
I agree to notify the business in writing of any changes in my account information or termination of this authorization 15 days prior to the next due date of the charges. For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these funds may be withdrawn from my account each month as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the company’s recurring billing with my bank; so long as the transaction corresponds to the terms indicated in this agreement. I also understand a return ACH fee may be imposed for transactions returned for any reason.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: