ACH Payments – The Laurel Group

Bill Pay Authorization – ACH Payments

Information and instructions.

To schedule your payment to be automatically deducted from your bank account, please complete and electronically sign the form below. Our office will securely keep a copy of this form on record and will charge your account for authorized work. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.”

By completing and submitting this form, you authorize The Laurel Group to complete transactions for amounts due as per a signed contract or agreement for projects or maintenance.

Laurel Group Payment Authorization Form (ACH)

First Name*
Last Name*
Email*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Invoice & Payment Information
Please complete this section to indicate the invoice and value to apply. Please also note if there are any special instructions.
Invoice Number(s)
Amount To Be Paid
Bank Account Information
Please complete this section for payments direct from bank accounts.
Account Type
Name On Acct
Bank Name
Account Number
Bank Rounting #
Bank State
State / Province / Region
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Bill Pay Authorization – ACH Payments

Laurel Group Payment Authorization Form (ACH)

Invoice & Payment Information

Bank Account Information

Huntington

Roslyn

Hamptons