Scribd
Upload
132 views1 page

Bank ACH Authorization Form

The document is an authorization for a one-time ACH payment of $5600.00 from CHIPMATIC INC to UNITED LANGUAGE GROUP for translation and localization services on 05/19/2024. It includes billing information, bank details, and terms regarding the payment process, including notifications for changes and NSF charges. The authorization remains in effect until canceled in writing with a 15-day notice prior to the next billing date.

Uploaded by

wd0009437
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
132 views1 page

Bank ACH Authorization Form

The document is an authorization for a one-time ACH payment of $5600.00 from CHIPMATIC INC to UNITED LANGUAGE GROUP for translation and localization services on 05/19/2024. It includes billing information, bank details, and terms regarding the payment process, including notifications for changes and NSF charges. The authorization remains in effect until canceled in writing with a 15-day notice prior to the next billing date.

Uploaded by

wd0009437
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

ONE TIME BANK (ACH) PAYMENT AUTHORIZATION

You authorize regularly scheduled withdrawals from your bank account. You will be charged the amount indicated
below each billing period. A receipt for each payment will be provided to you and the charge will appear on your bank
statement as an “ACH Debit”. You agree that no prior-notification will be provided unless the date or amount
changes, in which case you will receive notice from us at least ten (10) days prior to the payment being collected.

I, CHIPMATIC INC(Customer), authorize

UNITED LANGUAGE GROUP(Merchant) to charge my bank account indicated

below for $5600.00 on the 05/19/2024

This payment is for the following:TRANSLATION & LOCALIZATION .

BILLING INFORMATION

Billing Address: 212 OTTAWA ST City, State, ZIP: ELMORE OH 43416

Phone #: 4198622737 Email:

BANK DETAILS

Account Type: ☐ Savings | ☒ Checking

Account Name: CHIPMATIC INC

Bank Name: COMERICA BANK

Account Number (#):1852827516 Routing Number (#):072000096

ACCOUNT HOLDER SIGNATURE

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the Merchant, in
writing, of any changes to my account, or my request to terminate this authorization at least fifteen (15) days prior to
the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments
may be executed on the next business day. For ACH debits to my checking/savings account, I understand that
because these are electronic transactions, these funds may be withdrawn from my account as soon as the above
noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I
understand that the Merchant may, at its discretion, attempt to process the charge again within thirty (30) days. I
agree to an additional $[NSF CHARGE] charge for each attempt that is returned NSF, which will be initiated as a
separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions
to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account
and will not dispute these scheduled transactions with my bank, so long as the transactions correspond to the terms
indicated in this authorization form.

Account Holder’s Signature: ________________________________ Date: 05/19/2024

Printed Name: CHIPMATIC INC

Page 1 of 1

You might also like