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Credit Card Authorization Template – Illinois
Use this template to standardize intake, limit access, and keep authorization records easy to locate and audit.
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Credit Card Authorization Template
1. Business / Merchant Information
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]
2. Authorization Scope Statement
Authorization Scope: [Select: One-Time Charge only / Recurring Charges only / One-Time and Recurring as stated]
Authorized Amount and Currency: [Amount and Currency]
Statement Descriptor: [Descriptor / Business Name as it appears on card statements]
Internal Reference: [Customer ID / Ticket ID / Account ID]
3. Cardholder Information
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]
4. Card Details
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]
5. Charge Schedule Terms
One-Time Charge Date (if applicable): [Date]
Recurring Charge Amount (if applicable): [Amount and Currency]
Billing Frequency (if applicable): [Weekly / Monthly / Quarterly / Annually / Other]
First Charge Date (if applicable): [Start Date]
Final Charge Date or Until Cancelled (if applicable): [End Date or “Until Cancelled”]
Maximum Amount Per Billing Period (if applicable): [Maximum Amount and Currency]
6. Goods and/or Services
Description: [Brief Description of Goods and/or Services]
Invoice / Order / Account Number: [Reference Number]
7. Authorization and Agreements
Charge Authorization: [Cardholder authorizes Business / Merchant Name to charge the card listed for the amounts and schedule stated]
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]
8. Cancellation and Changes
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
In-Process Charges: [Charges already processed or in progress before the effective time may still be applied]
9. Internal Processing Checklist Table
Checklist items: [Mark completion status and keep with the authorization record]
Step | Owner | Completion Status | Date/Reference |
[Verify reference number matches invoice/order] | [Name/Role] | [Pending/Complete] | [MM/DD/YYYY / ID] |
[Confirm authorization type and amounts are filled] | [Name/Role] | [Pending/Complete] | [MM/DD/YYYY / ID] |
[Store authorization in designated location] | [Name/Role] | [Pending/Complete] | [MM/DD/YYYY / ID] |
[Record descriptor and customer contact channel] | [Name/Role] | [Pending/Complete] | [MM/DD/YYYY / ID] |
10. Access and Record Location
Record Storage Location: [Folder path / system name / link]
Access Role(s): [Role/Group with access]
Retention Preference: [Duration / owner / archive method]
11. Signatures
Cardholder Signature: [Signature]
Printed Name: [Cardholder Full Name]
Date: [Date]
Business Reviewer (Billing/Finance): [Name / Title / Signature / Date]
Business Reviewer (Customer Support): [Name / Title / Signature / Date]
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Learn more about
Credit Card Authorization Template – Illinois
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Illinois Credit Card Authorization Template FAQ
Why include an internal reference number on the authorization form?
An internal reference makes the authorization easier to retrieve and reconcile without relying on card details. When a customer calls with a billing question, staff can look up the record by account ID, ticket ID, or invoice number and quickly locate the signed consent. It also helps when multiple departments touch billing, because everyone can point to the same identifier for communications, receipts, and cancellations.
How can I keep authorizations consistent across staff members?
A checklist-based intake process reduces variation. The same fields should be completed every time: authorization type, amount, schedule, descriptor, and reference number. Adding a simple internal processing checklist ensures someone confirms that the authorization terms are complete and that the record is stored in the designated location. AI Lawyer can generate standardized versions of the form so each team uses the same structure and placeholders.
What details matter most when billing is recurring?
Recurring billing is clearest when it specifies the recurring amount, frequency, start date, and the end condition. If amounts can vary, a maximum per billing period provides a boundary that the cardholder can understand. Pair these terms with a clear cancellation channel and a processing window so customers know how to stop future charges and when that change takes effect.
Should I attach invoices or contracts to the authorization record?
Attaching supporting documents can be helpful as long as it improves traceability. A copy of the invoice, a receipt, or the relevant transaction reference can clarify what the authorization covers. The most important point is that the authorization can be matched to the underlying transaction, so staff can explain the charge. The template’s record location and attachment index fields help keep those documents linked.
What should be done when a customer says they did not authorize a charge?
Start by locating the authorization record using the internal reference and confirm what was authorized: amount, timing, descriptor, and goods or services description. If the authorization is incomplete or does not match the charge, treat it as an internal escalation and pause future billing under that authorization while you investigate. Keeping a clean audit trail of authorization, changes, and cancellations makes resolution easier.
How do I handle an updated billing address or contact email?
Update the customer record in your billing system and keep the authorization record linked to the same internal reference. The key is to maintain an accurate contact pathway for receipts, notices, and cancellation confirmations. If the update changes the identity of the account holder or creates uncertainty about consent, consider using a refreshed authorization tied to the updated record for clarity.
Is a signature the only way to document consent?
A signature is a strong method because it clearly indicates approval, but some workflows also document consent through secure portals or written confirmations tied to a reference number. Whatever method you use, the record should show who authorized the charge, what terms were authorized, and how the customer can request changes. The goal is that consent is specific, retrievable, and not ambiguous.
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