Fillable ACH RECURRING PAYMENT AUTHORIZATION FORM

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ACH RECURRING PAYMENT AUTHORIZATION FORM

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The ACH RECURRING PAYMENT AUTHORIZATION FORM form is 1 page long and contains:

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  • 3 check-boxes
  • 12 other fields

Country of origin: OTHERS
File type: PDF

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ACH RECURRING PAYMENT AUTHORIZATION FORM
Please read carefully. By completing the information below and your monthly lease payment will be automatically
withdrawn from the account you designate. The payment will be withdrawn on the scheduled due date each month. When
that date falls on a weekend or bank holiday, the payment will be withdrawn on the next business day but your lease
account will be credited with the payment on the scheduled due date. If you live in a jurisdiction that bills additional taxes
periodically, we will collect additional amounts owed through your ACH debit.
By signing above, I/we authorize Tesla Finance LLC, including its subsidiaries and affiliates (“Tesla Finance”) to initiate
withdrawals from the checking account or savings account shown above, for amounts due to Tesla Finance according to the
terms of my Lease Agreement. I may cancel this authorization by contacting Tesla Finance by phone at 844- TESLA85
(844-837-5285) or by email at teslafinance@tesla.com.
[Please attach a voided check for the above account here.]
*Please complete this form, attach a voided check for the above account or indicate you do not have voided checks.
This form may be scanned and emailed to teslafinance@tesla.com.
AN INCOMPLETE ACH FORM WILL VOID YOUR ENROLLMENT
Lessee Name(s)
Last 6 Digits of VIN
Phone Number
Email Address
ABA Routing Number
Account Number
Account Type
□ Checking
Bank Name
Bank City, State
Names(s) on Account
Signature(s)
I do not have a voided check and have reviewed the accuracy of the account number and routing number.
_____INITIALS
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ACH RECURRING PAYMENT AUTHORIZATION FORM

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Completed 10 February 2022

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