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.
First Name
Last Name
Amount (or amount range)*
BANK INFO
Name of Banking Institution*
City and State*
Banking Transit/ABA No. (Routing Number - 9 digits)*
Account No. (usually 10-12 digits, to right of the Routing Number on bottom of check)*
Exact Name as it appears on account*
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.

JGA charges $12 for valid ACH charges denied for insufficient funds.
Printed Name*
Authorized Signature*
Date*
MM slash DD slash YYYY
Email*
Therapist*
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Comments
This field is for validation purposes and should be left unchanged.

Updated: 8/12/2020

BANK INFO