Authorization Agreement for ACH Form

  • I, hereby authorize Jonah Green and Associates, LLC (“Company”) to initiate debit entries to my Checking Account indicated below and the bank/depository (“Bank”) named below, to debit the same such amount.


  • This authorization is to remain in full force and effect for until Jonah Green and Associates, LLC has received written notification from me of its termination. Written notification should be sent by first class mail to Jonah Green and Associates, LLC or electronically by email to my/our therapist’s email address should I/we wish to revoke this authorization. I/we understand that Jonah Green and Associates requires at least 5 business days prior notice in order to cancel this authorization.

  • MM slash DD slash YYYY

  • This field is for validation purposes and should be left unchanged.

Updated: 8/12/2020

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