Authorization Authorization Document
The form detailed herein is provided solely as a general template for obtaining pre-authorized payments related to your account. It is not intended to serve as legal advice and should not replace consultation with a qualified financial or legal professional. Regulations and requirements may differ based on jurisdiction, and appropriate modifications may be necessary to ensure full compliance. The use of this template is at the user’s own discretion and risk, and we accept no liability for any inaccuracies, omissions, or consequences resulting from its use without proper professional review.
Please note: This is a sample Pre-Authorized Debit (PAD) Authorization Form for California. Actual terms may vary based on specific agreements and applicable laws.
Pre-Authorized Debit (PAD) Form – California Sample
Parties Involved:
Bank: Example Bank, NA
Address: 1234 Finance Ave, Los Angeles, CA 90001
Account Holder: John Doe
Address: 789 Maple Street, Los Angeles, CA 90002
Authorization Instructions:
The undersigned authorizes Example Bank, NA to automatically debit the bank account specified below for recurring payments as detailed in this authorization. This authorization remains in effect until canceled by the account holder in writing, with a minimum of 15 days’ notice.
Bank Account Information:
Account Type: Checking / Savings
Account Number: ______________________
Routing Number: ______________________
Payment Details:
Amount: $__________
Frequency: Weekly / Biweekly / Monthly
Start Date: ____________
Terms & Conditions:
- This authorization is for the payment amount specified and may be amended upon mutual agreement.
- The account holder agrees to notify the bank and the payee of any discrepancies or cancellations at least 15 days prior to the next scheduled debit.
- This authorization complies with applicable California laws governing electronic funds transfers.
Location: ______________________ Date: ______________________
Signature of Account Holder