One-Time Preauthorized Payment Form
One Time Payment Authorization Form
No Refunds will be given unless previously approved by the Event Organizer or Director. All Refunds will be made in the form of a Check and mailed in the name of the Authorized User and/or Business Name Given to the address on this Authorization Form.
Vendor Fee Payment Withdrawal Date Must be processed at least 3 business days before the event, unless arrangements have been made with the event organizer.
Routing numbers must be 9 digits
No Special Characters or Dashes
I authorize the **Henryetta Chamber of Commerce** to initiate a **one‑time ACH debit** to my bank account listed in this form for the **payment amount** I have specified. This debit will occur on the **withdrawal date** I have provided. I understand this authorization applies **only to this single transaction** and does not establish recurring payments.
I certify that the **routing number**, **account number**, and **account type** provided are accurate and that I am an **authorized account holder** with full legal authority to permit ACH withdrawals from this account.
I understand that I may revoke this authorization **only in writing**, and that such revocation must be delivered to the Henryetta Chamber of Commerce at least **two (2) weeks prior** to the scheduled withdrawal date. Revocation must be submitted to the Chamber office in person.
I understand that if the ACH debit is returned unpaid for any reason — including insufficient funds, closed account, or incorrect information — the Chamber may **reattempt the debit** and may assess any applicable **bank‑imposed return fees**.
I understand that my banking information will be used solely for processing this ACH transaction. The Henryetta Chamber of Commerce will store this authorization securely and restrict access to authorized personnel only. My information will not be shared except as required to complete the ACH transaction or comply with applicable law. **Record Retention** I understand that this authorization will be retained by the Henryetta Chamber of Commerce for a minimum of **two (2) years**, as required for ACH compliance.
By signing below, I confirm that: - I am an authorized user of the bank account listed; - I authorize this **one‑time ACH payment**; - I agree to all terms stated in this authorization; - The information I have provided is true and correct.
Typed Signature is a Confirmation of Authorization to Pull One Time Payment Via ACH Electronic Transfer

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