ACH Debit Authorization Form

This form authorizes Revenue Cycle Solutions, LLC to collect your monthly service invoice by electronic bank transfer (ACH). Complete every field and sign.

1 Client Information

Legal Business Name *

Federal Tax ID (EIN) *

Email for Invoices *

Street Address *

City *

State *

ZIP *

Business Phone *

2 Bank Account to Be Debited

Name on Account * (as the bank shows it)

Financial Institution *

Routing Number * (9 digits)

Account Type *

Checking Savings

Account Number *

Re-enter Account Number *

First debit on or after * (locked to your signature date)

3 Authorization

I, the Authorized Signer identified by my signature in Section 7, give Revenue Cycle Solutions, LLC (“RCS”) a recurring authorization to initiate electronic debit entries (ACH) against the account identified in Section 2 for monthly service payments under our Services Agreement, and to initiate any credit or adjusting entry needed to correct an error.

Amount: Variable. Each debit equals the invoice amount RCS emails you for that month.
Timing: On the payment due date identified in the Services Agreement, or the first business day after it if that date falls on a weekend or bank holiday.
Frequency: Monthly, beginning on the date of this signed form.
Statement: These debits appear on your bank statement as CertifiedReimbu (Company ID 1383415740).
Rules: Client and RCS will comply with U.S. law and all applicable Nacha Operating Rules. RCS will give you a copy of this authorization and will keep it on file for at least two years after it terminates.

4 Changes

To change the bank, the account, or the authorized signer — send written notice to Invoices@certifiedrsllc.com at least 14 business days before the next scheduled debit. That lead time gives RCS and the financial institution a reasonable opportunity to act on your notice.

Nothing in this form limits any right you have under law.

5 Returned Payments

A transfer that fails for insufficient funds is non-payment under the Services Agreement. If a debit is returned or declined for any reason, RCS may charge a returned-payment fee equal to the lesser of $50.00 or the maximum amount permitted by applicable state law.

6 Electronic Signature & Records

Consent. I agree to sign this authorization electronically and to receive this authorization, invoices, and related notices electronically at the email address in Section 1. An electronic signature and an electronic record have the same legal effect as a handwritten signature on paper.

Scope. This consent covers this authorization and all records and notices related to it, for as long as it stays in effect.

7 Certification & Signature

By signing below, I certify that I am an authorized signer on the account in Section 2 and am authorized to bind Client to this authorization; that the information on this form is accurate and complete; and that I have read, understand, and agree to Sections 3 through 6 and have received a copy of this authorization.

Printed Name (Authorized Signer) *

Title *

Phone *

Email *

Signature *

Sign above with your mouse or finger

Date * (locked to today)

Your signed authorization is submitted securely to Revenue Cycle Solutions. No bank details are sent by email.