USA Hospitality, INC

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ACH Payment Authorization Form — Bank Draft / Electronic Payment Authorization

Schedule your payment to be automatically deducted from your bank account. Complete and sign this form to get started. Fields marked with * are required.

ACH payments will 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), helping eliminate late charges.

How recurring ACH payments work

You authorize USA Hospitality, Inc. to initiate ACH debit entries to your checking or savings account per invoice delivery. You will be charged the amount indicated on each invoice. A receipt for each payment will be emailed to you, 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 immediately prior to the payment being collected.

Please complete the information below:

Authorization terms & acknowledgments (Orange County, Florida)

By completing and submitting this ACH Authorization Form, the Applicant (“you”) authorizes USA Hospitality, Inc. (“USA Hospitality”) to initiate electronic debit entries (“ACH Debits”) to the bank account provided in this form for payment of invoices, in accordance with the terms set forth herein. You further acknowledge that any dispute between the parties related to this authorization may be litigated in the appropriate court in Orange County, Florida, unless otherwise required by applicable law.

Ongoing authorization: I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify USA Hospitality, Inc. in writing of any changes to my account information or termination of this authorization at least fifteen (15) days prior to the next invoice payment.
Payment timing: If a scheduled payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. Because ACH transactions are electronic, I understand that funds may be withdrawn from my account as soon as the periodic transaction date(s) indicated by invoice delivery.
NSF / rejected transactions: In the case of an ACH transaction being rejected for Non Sufficient Funds (NSF), I understand that USA Hospitality, Inc. may, at its discretion, attempt to process the charge again within thirty (30) days. I agree to an additional $50.00 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized recurring payment.
Compliance with law: I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
Authority & non-dispute acknowledgment: I certify that I am an authorized user of this bank account (and, if applicable, any linked payment method) and will not dispute these scheduled transactions with my bank, so long as the transactions correspond to the terms indicated in this authorization form.

Important: Please ensure the account details provided are accurate. Incorrect routing or account numbers may delay processing.

What you will need to complete this authorization

Legal business name and billing address.
Bank name, routing number, and account number.
Billing contact email for payment confirmations and receipts.
Authorized officer name, title, and signature (digital signature accepted).

Security note: For your protection, do not include sensitive information in open email threads. Submit this form through the secure form submission page whenever available.

By submitting this authorization, you confirm you are authorized to act on behalf of the Applicant and that the information provided is accurate.

Voided Check Required (Mandatory) — For ACH Payment Authorization

To activate ACH (bank draft) payments, a voided check is required. The voided check is used to verify the routing number and account number for the bank account you are authorizing. This helps ensure payments are drafted from the correct account and reduces the risk of delays, rejected transactions, and misapplied payments.

Why the voided check is important

Accuracy: Confirms the correct routing and account numbers directly from your bank-issued check.
Security & fraud prevention: Helps validate the account owner and reduces the risk of unauthorized or incorrect account drafts.
Fewer NSF/returns: Minimizes bank rejections caused by incorrect digits, which can result in fees and delays.
Compliance: Supports standard ACH onboarding practices and internal controls for payment processing.

How to prepare your voided check

Write “VOID” in large letters across the front of the check (do not cover the routing/account numbers at the bottom).
Take a clear photo or scan of the voided check.
Upload it using the Voided Check upload field in this form.
Ensure the following are readable: Bank Name, Routing Number (9 digits), and Account Number.

Important: A deposit slip is not accepted as a substitute. If you do not have checks available, please contact USA Hospitality, Inc. for an approved alternative verification method.

Sample voided check showing routing number, account number, and check number for ACH setup

Required: Attach a voided check from the account that will be used for ACH payments.

Why a voided check is mandatory for ACH authorization

A voided check helps confirm the bank routing number and account number exactly as your bank has them on file. This reduces processing delays, prevents payment errors, and supports secure verification for recurring ACH debits.

How to prepare your voided check

Write “VOID” across the check in large letters.
Do not sign the check and do not write an amount.
Upload a clear photo or scan showing the routing and account numbers.
Use a check from the same account that will be authorized for ACH debits.

Security note: USA Hospitality, Inc. uses this document only to validate the bank information you authorize in this form and to help process ACH debits accurately.

ACH Payment Form

Attach the Void Check *

I had attached the void check.

Attach the void check here: *

These are our terms and conditions for the ACH Authorization Form *

I agree with the terms and conditions of this authorization.

Company Name: *

Company Billing Address Number: *

Company Billing Street Name: *

Company Billing City Name: *

Company Billing State *

Company Billing Zip Code *

Company Phone Number: *

Company E-mail: *

Bank Account Authorized Officer's Name: *

Authorized Person's Title in the Company: *

Bank Name: *

Account Branch Bank Address Number: *

Account Branch Address Street Name: *

Account Branch City Name: *

Account Branch State Name: *

Account Branch Zip Code *

Acount Branch Phone Number *

Account Type *

Checking Account Savings Account

Account Exact Name: *

Account Bank Routing Number: *

Account Number *

What happens after you submit

We review the Applicant and banking details for completeness.
We confirm the authorized signer and contact information on file.
We activate ACH payment authorization and notify you when it is ready for use.

Need help?

If you experience any issues completing this authorization, please contact our team for assistance.

By submitting this ACH Authorization Form, you confirm you are authorized to approve electronic payments on behalf of the Applicant. This authorization may be used to pay for USA Hospitality, Inc. purchases and related charges in accordance with your business’s purchasing activity.