Automatic Withdrawal Authorization (ACH) Church Contributions Form

The Automatic Withdrawal Authorization (ACH) church contributions form is available free below to download, customize and print for your church or organization's administrative office, Human Resources Department, etc.



What is an ACH form?

An Automated Clearing House (ACH) authorization form is a payment authorization that you fill out that gives the organization permission to electronically take money from your bank, credit union, or prepaid card account when your payment is due. You can revoke this authorization at any time.



Your church or organization must have an ACH form of this type to be able to debit from your donor's bank account, credit union or prepaid card account. This form has to be completed filled out by the donor and returned to your church office before any deduction can be started.

There's no standardized format for an ACH Authorization form, but each one requires a set of mandatory elements. At a minimum the form must have:

  • Request permission for all future debits, allowing your organization to collect varying amounts from your donors.
  • Collect the necessary banking details to submit payments through the ACH Network.
  • Explain to the donor how they can revoke their authorization.

The necessary banking details to collect include:

The Form for Donations below includes:

  • Church or Organization's Name - 
  • Payer's Name
  • Payer's Email Address (For online transactions)
  • The Account to be Debited: 
  • 1. Checking or Savings Account 
  • 2. Bank Name 
  • 3. Routing and Account Number
  •  Not to be Exceeded Amount (For recurring payments)
  • Frequency (For recurring payments)
  • Start Date (For recurring payments)

The ACH form below includes:

  • Form Title
  • Church or Organization's Name, Address and Phone Number
  • Bible Scripture - 1 Peter 4:10
  • Account Information - Bank account information and/or credit card information.
  • Contribution Schedule - Fund Type, Payment Schedule, Amount, Payment Start Date and Collection Date (Date to be withdrawn from your account).
  • Statement - I authorize the above-named church to debit from the account specified on this form. This authorization will remain in effect until I give reasonable change or cancellation notice to terminate authorization. I understand there will be a $____ nonsufficient funds (NSF) fee charged to my account for NSF debits.
  • Authorized Account Signature and Date
  • Contribution Envelope Number
  • Confidentiality Statement The above information will not be disclosed to any unauthorized personnel or financial institutions.
  • PLEASE RETURN COMPLETED FORM, ALONG WITH A VOIDED CHECK (CHECKING ACCOUNT) TO: [Contact Name & Title]  │  [Church Name]  │  [Church Address]  │  [Church City, State & Zip Code] A copy of this form will be returned to you along with a letter of acknowledgement.
Click on the link to download the form for donations below:

Automatic Withdrawal Authorization (ACH) Church Contributions Form


If you need to modify this form, try the site: Free PDF Services. You can convert this Adobe file into a Word document free of charge and make the necessary changes.

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Note: These sample forms are meant to serve as example forms and should not be construed as legal documents.  Please contact a legal professional for legal language for your specific organization.


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