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The form collects name on account, case number, billing address, contact information, and checking/savings routing and account numbers, then requires acknowledgment of legal ownership and account validity. It authorizes Louisiana Interactive (or agent) to debit and, if needed, correct erroneous debits via ACH, states NACHA and applicable U.S./state compliance, includes transaction Originating ID, payment amount and fees, and provides submission instructions to email LAPELS Enforcement or mail the signed form.","Electronic Check Authorization Form  \n(U.S. Banks only)  \nPLEASE DOWNLOAD AND COMPLETE THIS AUTHORIZATION FORM All information will remain confidential.  \nName on Account:  \nCase Number:  \nThis is a business account  \nBilling Address:  \nCity: State:  Zip Code:  \nCountry: select country  \nPhone Number: Email:  \nChecking Savings Routing Number: Account Number:  \nYes, I authorize this transaction. Please print this page if you would like a copy of this authorization foryour records. By checking “Yes” and opting to pay by electronic debit against the bank account specified above, I agree and stipulate to all statements:  \n1. I am the legal owner, have power of attorney, or have legal authority in relation to the bank account specified above tobe used for payment.  \n2. Such bank account is open, validly issued, in good standing and able to accept electronic debits.  \n3. Louisiana Interactive or its agent is authorized to electronically debit the bank account shown above, and if necessary, to credit such account to correct any erroneous debits using an Automated Clearing House (“ACH”) debit entry.  \n4. This ACH debit authorization will remain in full force and effect for this single debit entry only.  \n5. Louisiana Interactive or its agent may re-debit my account for the payment in the event such is dishonored by my financial institution, and is additionally authorized to charge the maximum return item processing fee according to the laws governing Louisiana Interactive's state.  \n6. For inquiries relating to this electronic debit authorization, including revocation of this authorization, I may contact Louisiana Interactive at 225-325-5450.  \n7. I understand the Originating ID for this transaction is “1522077581”. Please make sure your banking institution has released any debit blocks (if applicable) for this ID to ensure successful payment.  \nI (we) agree that ACH transactions I (we) authorized comply with all applicable NACHA Rules and all applicable US law and the laws governing Louisiana Interactive's state.  \nAmount to Charge (USD): Electronic signature:  \nFee: $ (type your name)  \nService Fee: $  \nTotal: $ Date:  \nOnce signed, click the Submit button below to email to LAPELS Enforcement staff, or return by mail with any requested documentation to the following address:  \nLAPELS  \nATTN: ENFORCEMENT  \n8550 UNITED PLAZA BOULEVARD, SUITE 903  \nBATON ROUGE, LA 70809","cbCaihk4l43aMFq0","https://ap.wps.com/l/cbCaihk4l43aMFq0","pdf",1952627,"English","en",105,"# Authorization Overview\n## Account and Billing Information\n## Authorization Statements and Transaction Rules\n## Payment Details and Submission Instructions","[{\"question\":\"Who is allowed to use this electronic check authorization form?\",\"answer\":\"The form is designated for U.S. banks only.\"},{\"question\":\"What does the “Yes, I authorize this transaction” consent cover?\",\"answer\":\"It authorizes Louisiana Interactive (or its agent) to electronically debit the specified bank account for a single ACH debit and, if needed, to correct erroneous debits.\"},{\"question\":\"How can the authorization be submitted after signing?\",\"answer\":\"After signing, submit via the Submit button to email LAPELS Enforcement staff or return by mail to LAPELS, ATTN: ENFORCEMENT, 8550 UNITED PLAZA BOULEVARD, SUITE 903, BATON ROUGE, LA 70809.\"}]","Electronic Check Authorization Form (U.S. Banks only) | PDF",1789633878,{"code":4,"msg":74,"data":75},"ok",{"site_id":68,"language":67,"slug":76,"title":59,"keywords":77,"description":60,"schema_data":78,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"electronic-check-authorization-form-us-banks-only","",{"@graph":79,"@context":133},[80,96,116],{"@type":81,"itemListElement":82},"BreadcrumbList",[83,87,90,93],{"item":84,"name":85,"@type":86,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":88,"name":10,"@type":86,"position":89},"https://docshare.wps.com/template/",2,{"item":91,"name":36,"@type":86,"position":92},"https://docshare.wps.com/template/forms/",3,{"item":94,"name":59,"@type":86,"position":95},"https://docshare.wps.com/template/electronic-check-authorization-form-us-banks-only/288760/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":67,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/electronic-check-authorization-form-us-banks-only/288760.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":84,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":113,"interactionType":114,"userInteractionCount":15},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"Who is allowed to use this electronic check authorization form?","Question",{"text":123,"@type":124},"The form is designated for U.S. banks only.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"What does the “Yes, I authorize this transaction” consent cover?",{"text":128,"@type":124},"It authorizes Louisiana Interactive (or its agent) to electronically debit the specified bank account for a single ACH debit and, if needed, to correct erroneous debits.",{"name":130,"@type":121,"acceptedAnswer":131},"How can the authorization be submitted after signing?",{"text":132,"@type":124},"After signing, submit via the Submit button to email LAPELS Enforcement staff or return by mail to LAPELS, ATTN: ENFORCEMENT, 8550 UNITED PLAZA BOULEVARD, SUITE 903, BATON ROUGE, LA 70809.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":68},1791014472]