ACH PAYMENT AUTHORIZATION FORM
I (we) authorize the Delaware River Basin Commission (“DRBC”) to electronically debit my (our) account and, if
necessary, electronically credit my (our) account to correct erroneous debits as follows:
Company Name on Account
Select One: Checking Account Savings Account
Depository (Bank) Name
Routing Number (9-digits)
Account Number
Amount of debit authorization $
on or after the following date
Invoice Number(s) (preferred), or docket number and/or payment description:
I certify that I am an authorized representative of the Company indicated above and that I have the authority
to authorize this payment on the Company’s behalf. Company understands that because this is an electronic
transaction, these funds may be withdrawn from its account as soon as the above noted transaction date, and
that it will have limited time to report and dispute errors. In the case the transaction is returned for Non-
Sufficient Funds (NSF), Company understands that DRBC may, at its discretion, attempt to process the charge
again within 30 days and agrees to an additional $35 charge for each attempt returned NSF, which will be
initiated as a separate transaction from the authorized payment. Company has certified that the above
business bank account is enabled for ACH transactions and agrees to reimburse DRBC for all penalties and fees
incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being
properly configured for ACH transactions. Both parties agree to be bound by NACHA Operating Rules as they
pertain to this transaction. Company acknowledges that the origination of the ACH transactions to its account
must comply with the provision of U.S. law. Company agrees not to dispute this transaction with its bank
provided the transaction corresponds to the terms indicated in this authorization form.
Name (Please Print)
Title
Phone
Signature
