Introducing Referent – AI-native practice management software for modern law firms.
Explore ReferentAuthorization Type: [Select: One-Time Charge / Recurring Charges]
Authorized Amount (one-time): [Amount and Currency]
Date of Charge (one-time): [Date]
Recurring Charge Amount (if recurring): [Amount and Currency]
Billing Frequency (if recurring): [Weekly / Monthly / Quarterly / Annually / Other]
First Charge Date (if recurring): [Start Date]
Final Charge Date or Until Cancelled (if recurring): [End Date or “Until Cancelled”]
Maximum Amount Per Billing Period (if applicable): [Maximum Amount and Currency]
Cardholder Name: [Cardholder Full Name (as it appears on the card)]
Billing Address: [Street Address], [City], [State/Province], [ZIP/Postal Code], [Country]
Phone: [Cardholder Phone Number]
Email: [Cardholder Email Address]
Type of Card: [Select: Visa / Mastercard / American Express / Discover / Other: Card Type]
Card Number: [XXXX-XXXX-XXXX-XXXX]
Expiration Date: [MM/YY]
Security Code: [XXX]
Name of Issuing Bank: [Bank Name]
Business / Merchant Name: [Business / Merchant Name]
Business Address: [Business Address], [City], [State/Province], [ZIP/Postal Code], [Country]
Phone: [Business Phone Number]
Email: [Billing Email Address]
Website: [Website URL]
Description: [Brief Description of Goods and/or Services]
Invoice / Order / Account Number: [Reference Number]
Consent to Charge: [Cardholder authorizes Business / Merchant Name to charge the card for the amount(s) and schedule stated]
Statement Descriptor: [Descriptor / Business Name as it appears on card statements]
Authorized User Confirmation: [Cardholder confirms they are the authorized cardholder or authorized user]
Billing Information Updates: [Cardholder will promptly communicate changes to card details or billing information]
Parameters: [Use this table to restate recurring terms in a single view]
Frequency | Charge Amount | Billing Cap | Start Date | End Date/Until Cancelled |
[Monthly/Other] | [Amount and Currency] | [Maximum Amount and Currency] | [MM/DD/YYYY] | [MM/DD/YYYY or Until Cancelled] |
[Monthly/Other] | [Amount and Currency] | [Maximum Amount and Currency] | [MM/DD/YYYY] | [MM/DD/YYYY or Until Cancelled] |
Frequency | Charge Amount | Billing Cap | Start Date | End Date/Until Cancelled |
[Monthly/Other] | [Amount and Currency] | [Maximum Amount and Currency] | [MM/DD/YYYY] | [MM/DD/YYYY or Until Cancelled] |
[Monthly/Other] | [Amount and Currency] | [Maximum Amount and Currency] | [MM/DD/YYYY] | [MM/DD/YYYY or Until Cancelled] |
Frequency
Charge Amount
Billing Cap
Start Date
End Date/Until Cancelled
[Monthly/Other]
[Amount and Currency]
[Maximum Amount and Currency]
[MM/DD/YYYY]
[MM/DD/YYYY or Until Cancelled]
Change Requested By: [Name]
Request Date: [MM/DD/YYYY]
Requested Change: [Select: amount change / frequency change / end date change / descriptor change / other]
New Terms (if approved): [Describe updated amount, schedule, and caps]
Approval of Change (Cardholder): [Signature / Date]
Approval of Change (Business): [Name / Title / Signature / Date]
Cancellation Notice Email: [Billing or Support Email Address]
Cancellation Notice Mailing Address: [Billing Department Address]
Cancellation Effective After: [Number] business days from receipt of written notice
Customer Support Contact: [Support phone / email for billing questions]
Cardholder Signature: [Signature]
Printed Name: [Cardholder Full Name]
Date: [Date]
Business Billing Manager Signature: [Name / Title / Signature / Date]
Frequency | Charge Amount | Billing Cap | Start Date | End Date/Until Cancelled |
[Monthly/Other] | [Amount and Currency] | [Maximum Amount and Currency] | [MM/DD/YYYY] | [MM/DD/YYYY or Until Cancelled] |
[Monthly/Other] | [Amount and Currency] | [Maximum Amount and Currency] | [MM/DD/YYYY] | [MM/DD/YYYY or Until Cancelled] |
Each template already follows legal structure and best practices.
The agreement is automatically filled and adapted to your inputs.
Check the generated document, make edits if needed, and download a ready-to-use agreement.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Frequently asked
A billing cap clarifies the outer limit of what the cardholder is approving for a given period, which can be useful when charges may vary due to usage, add-ons, or proration. It sets expectations up front and makes it easier to explain billing when statements arrive. If your pricing is fixed, you can still include a cap that matches the recurring amount to reinforce what “normal” looks like for the customer.
Use a short change record that states what changed, the new terms, and who approved it. The most important details are the revised amount, the revised schedule, and whether the cap or end date changed. Keeping the change record attached to the original authorization helps the business show a continuous consent history. AI Lawyer can generate a consistent change record layout so updates are captured the same way across accounts.
For one-time charges, specifying a charge date reduces confusion. For recurring charges, the schedule can be expressed through a start date and a frequency, with an end condition such as a final date or “until cancelled.” The key is that the customer can understand when charges will happen and for what amounts. If timing is uncertain, consider waiting to charge until an invoice is issued and tied to the authorization reference.
Descriptor confusion is common when the business name on a website differs from the processing descriptor. Including the descriptor field helps reduce that risk because customers see in advance what the statement line will likely say. If your descriptor changes by product line, capture the exact version used for processing. When questions arise, the signed authorization with the descriptor field can help resolve the issue faster.
Yes, because a reference number helps both parties match the charge to the underlying account or subscription record. For subscriptions, you can use an account number, membership ID, or subscription ID instead of a one-time order number. This is useful for customer support, cancellations, and reconciliation. It also makes internal billing notes easier to track across renewals.
Only capture what your workflow truly needs and keep access controlled. Many businesses process payments through secure systems that reduce the need to keep full details in a document. If you do keep completed forms, store them in a restricted location and maintain a consistent internal reference so the record can be found without copying card information into multiple places. The goal is to document consent while minimizing unnecessary handling.
A receipt confirms that a payment occurred, while an authorization form documents permission to charge. The authorization typically exists before or at the time of charging, and it defines the terms for future charges if recurring billing is involved. Using both together is common: the authorization records consent, and receipts or invoices provide the transactional record for accounting and customer reference.
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