Payment Authorization Form Template

[Business / Merchant Name]
[Business Address]
[City, State/Province, ZIP/Postal Code, Country]
Phone: [Business Phone Number]
Email: [Billing Email Address]
Website: [Website URL]

PAYMENT AUTHORIZATION FORM

1. Payer Information

Payer Name:
[Full Legal Name]

Billing Address:
[Street Address]
[City, State/Province, ZIP/Postal Code, Country]

Contact Details:
Phone: [Phone Number]
Email: [Email Address]

2. Payment Method

Select the payment method to be authorized and complete the relevant details.

Card Payment
☐ Credit Card
☐ Debit Card

Card Type: [Visa / Mastercard / American Express / Discover / Other]
Name on Card: [As it appears on the card]
Card Number: [XXXX-XXXX-XXXX-XXXX]
Expiration Date (MM/YY): [MM/YY]
Security Code (CVV/CVC): [XXX]
Issuing Bank: [Bank Name]

Bank Account / Direct Debit
☐ Bank Account / ACH / Direct Debit

Account Holder Name: [Name]
Bank Name: [Bank Name]
Bank Address: [Bank Address]
Account Number / IBAN: [Account Number / IBAN]
Routing Number / Sort Code / BIC/SWIFT: [Number]

3. Type of Authorization and Limits

Please mark the type of authorization being granted.

☐ One-Time Payment Authorization

Authorized Amount: [Amount and Currency]
Date of Charge: [MM/DD/YYYY]

☐ Recurring / Ongoing Payment Authorization

Regular Payment Amount: [Amount and Currency]
Billing Frequency: [Weekly / Monthly / Quarterly / Annually / Per Invoice / Other]
First Charge Date: [MM/DD/YYYY]
Final Charge Date or “Until Cancelled”: [MM/DD/YYYY or “Until Cancelled”]

Maximum Amount Per Billing Period (if used): [Amount and Currency]

4. Description and Reference

Description of Goods and/or Services:
[Short description of what the payment covers]

Invoice / Order / Contract / Account Number:
[Reference Number]

5. Authorization and Agreements

By signing below, I:

1. Authorize [Business / Merchant Name] to initiate charges to the payment method listed in Section 2 in the amounts and on the schedule described in Section 3 for the goods/services described in Section 4.

2. Confirm that I am the authorized cardholder or account holder, or that I am otherwise authorized to approve charges on this payment method.

3. Understand that, for recurring charges, this authorization will remain in effect until the final charge date stated in Section 3 or until I cancel it as described in Section 6.

4. Agree to maintain valid and up-to-date payment details and to notify [Business / Merchant Name] promptly if my card or account information changes or is cancelled.

5. Understand that charges may appear on my statement under the name [Statement Descriptor / Business Name as shown to bank/card].

6. Cancellation and Changes (Recurring Payments)

For recurring or ongoing payments, the payer may cancel or change this authorization by contacting:

Billing Email: [Billing or Support Email Address]
Billing Phone: [Billing or Support Phone Number]
Mailing Address: [Billing Department Address]

Cancellation or change requests should be made in writing, where possible. Requests will take effect after [Number] business days from receipt. Any charges already processed or initiated before the request is processed may still be applied.

7. Payer Certification and Signature

I certify that the information provided in this form is true and correct. I have read and understood this Payment Authorization Form and agree to be bound by its terms.

Payer Signature: _________________________________

Printed Name: [Payer Full Name]

Date: [MM/DD/YYYY]

8. For Business Use Only

Internal Customer ID / Account No.: [Internal Reference]
Authorized By (Staff Name/ID): [Name or ID]
Date Received: [MM/DD/YYYY]
Notes:
[Internal notes or approvals, if any]