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Payment Authorization Form Template
Document your customer’s permission to charge their card or bank account with a simple, professional authorization form.
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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:
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.
Confirm that I am the authorized cardholder or account holder, or that I am otherwise authorized to approve charges on this payment method.
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.
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.
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]
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Learn more about
Payment Authorization Form Template
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.
PAYMENT AUTHORIZATION FORM TEMPLATE FAQ
What is a payment authorization form?
A payment authorization form is a document where a customer or payer gives written permission for a business to charge their credit/debit card or bank account. It records the payer’s details, payment method, amount or billing rules, and their consent, usually confirmed by signature and date.
When should I use a payment authorization form?
Use a payment authorization form whenever you need clear proof that a customer agreed to a charge, especially for phone/email orders, recurring subscriptions, installment plans, retainers, or automatic invoicing. It helps reduce disputes by showing the payer approved the transaction.
What should a payment authorization form include?
A good form includes: payer and business details, payment method (card or bank account), the amount or pricing terms, whether charges are one-time or recurring, billing frequency, start/end dates, and a signed statement of consent. It should also explain how the payer can cancel recurring charges.
Is a payment authorization form the same as a contract or invoice?
No. A contract describes the overall business deal, and an invoice shows what is being billed. A payment authorization form focuses on the payer’s permission to charge their card or account under those agreed terms. It is usually used together with contracts, quotes, or invoices.
Does a signed payment authorization form prevent all chargebacks or disputes?
No. Card networks and banks make their own decisions under their rules. A signed form does not guarantee that a chargeback will never happen, but it is useful evidence that the payer consented to the charge.
Can AI Lawyer help me customize this payment authorization form?
Yes. AI Lawyer can help you tailor this payment authorization form template to your business by adjusting the wording, adding your logo and branding, and aligning it with your billing and cancellation policies. You still decide the commercial terms and remain responsible for compliance with card network rules and local law.
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