ACH Recurring Payment Authorization Form

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Schedule your payment to be automatically deducted from your checking or savings account. Just complete and sign this form to get started!

We Make Your Life Easier

It’s convenient (saving you time and postage)
Your payment is always on time (even if you’re out of town).

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking or savings account. You will be charged the amount indicated below each billing period and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

Please complete the information below:

I, authorize Alpha Recovery Corp. to collect the following payment(s),

    payable up to 6 scheduled payments. I understand payments should be a

minimum of $25 and the first payment should not be any later than 60 days from today and the subsequent payments should not

be any further apart than 60 days from each other.

Authorized Scheduled Payments

Payment Dates(s)                        Payment Amount(s)







Consumer Information

ARC Account #:

Address of Consumer:

City, State, Zip of Consumer:

Phone # of Consumer


Example Check

Financial Institution

Checking Account Information

Name on Check (can be different than the Consumers information):

Bank Name:

Account Number (please include all zero numbers)

Address on Check:
Bank Routing #

Bank City/State:

City, State, Zip on Check:

E-SIGNATURE (Just type your full name):     DATE:


Please type in the code below