U.S. Bank ACH Authorization
The purpose of the U.S. Bank ACH Authorization is to obtain authorization to add accounts to your ACH service(s). Please complete, sign and return
this form to the contact provided below.
Company Name:
Tax ID Number (TIN):
Phone Number:
Settlement/Origination Account Information
This section must be completed for all origination channels.
Enter the Account Number(s) and Tax ID(s) that will be utilized for Settlement/Origination. Also indicate if the settlement account is authorized for Same
Day ACH Processing (additional fees apply).
Account Number
Tax ID
Same Day ACH Processing (Optional)
SinglePoint/SinglePoint Essentials Same Day Origination
This section should only be completed to authorize Same Day ACH Origination through SinglePoint/SinglePoint Essentials.
Enter the SinglePoint Customer ID authorized for Same Day ACH. Access to Same Day ACH Processing is granted at the customer level in SinglePoint.
When Same Day ACH Processing is requested on an authorized settlement/origination account in SinglePoint, all settlement/origination accounts under
the same Customer ID will be authorized for Same Day Origination through SinglePoint.
SinglePoint Customer ID:
Comments
Customer Approval
By signing this Authorization Form, Customer represents and warrants that all selections, designations, and/or other instructions contained herein are
accurate and have been authorized by Customer, that the Services requested herein shall be governed by the U.S. Bank Services Terms and
Conditions, or other contract governing the provision of Treasury Management services approved in writing by Bank, and that the signer listed below is
an authorized signer. In addition, Customer agrees to adhere to the NACHA Operating Rules. Bank may rely on the information contained in this
Authorization Form until it has been revoked in writing by Customer and Bank has had a reasonable opportunity to act on any such revocation.
Customer acknowledges and agrees that U.S. Bank may conclusively rely on facsimiles or other photocopies or images of this Authorization Form as an
original document.
Same Day ACH
If Customer authorizes Same Day ACH, Customer agrees that:
(a) All eligible ACH transactions submitted with a same day effective date will be processed as a Same Day ACH transaction;
(b) Customer shall comply with all NACHA Same Day ACH Guidelines, including, but not limited to, adhering to per transaction and aggregate per
receiver or per invoice dollar limits, standard entry class, and submission deadlines;
(c) Authorization applies to both Credit (effective September 2016) and Debit (effective September 2017) transactions, and to all ACH services
requested by the customer at setup;
(d) Bank will set up Company IDs and origination channels based on Customer request.
Remittance Transfer Provider - 12 CFR Part 1005 (Regulation E)
If Customer is classified as a Remittance Transfer Provider under Regulation E, Customer represents, warrants and agrees that:
(a) Customer shall perform and comply with the requirements of 12 CFR Part 1005, including, but not limited to, providing the disclosures to the
consumer (sender) as set forth in section 1005.31, being responsible for the error resolution procedures and the provision of any remedies to the
consumer (sender) as set forth in section 1005.33, and being responsible for the cancellation and refund of Remittance Transfers as set forth in section
1005.34;
(b) Bank is acting as an agent and not as a Remittance Transfer Provider when performing activities on behalf of Customer; and
(c) Even if Bank is deemed a Remittance Transfer Provider under applicable law, Customer shall take all actions necessary to comply with the
obligations of a Remittance Transfer Provider.
Customer agrees to indemnify and hold Bank harmless from and against any and all loss, liability, damage, costs and expenses (including attorneys’
fees) that Bank may sustain in reliance on Customer’s representations and warranties set forth herein.
Authorized Signer:
(please print)
Signature:
Rev 6/16
Title:
Date:
Phone Number:
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Treasury Management Contact Information
Please return the completed and signed form, via fax or email, to:
Contact Name:
Fax Number:
Phone:
Email Address:
@usbank.com
For U.S. Bank Internal Use Only
Yes Date:
Verified by:
Relationship Manager or Account Officer signature required if a contract is not currently on file or the Authorized Signer above is not listed on the
contract. I hereby verify that the above signer is authorized to approve services on behalf of the customer.
TM Implementation: Authorized Signer is listed on TM Contract/Appendix B
Account Officer's
Name:
(please print)
Signature:
Rev 6/16
Officer
Code:
Title:
Date:
Phone
Number:
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