One Time ACH Payment Authorization Form

One Time ACH Payment Authorization Form

Please fill out the form below to authorize YayYo, Inc. to make a one time debit to your checking or savings account.

By filling out your name on  this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

Select "C" for Checking or "S" for Savings


I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of the payment being rejected for Non Sufficient Funds (NSF) I understand YayYo, Inc. may at its discretion attempt to process the charge again within 30 days, and I agree to an additional $25 for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute YayYo Inc’s billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.

If you’re having difficulty completing the form above or would prefer to download the form and email it to or fax it to 888-388-9074, click here.