Introducing Referent – AI-native practice management software for modern law firms.
Explore ReferentMerchant/Service Provider Name: [Business Name]
[Address]
[Phone] | [Email]
[Website (Optional)]
Customer Name: [Full Name / Business Name]
Account/Invoice Number (Optional): [Number]
Date: [Date]
1.1 Billing Type (Select One):
☐ Fixed amount recurring payments
☐ Variable amount recurring payments (amount may change)
2.1 Payment Method (Select One):
☐ Credit/Debit Card ☐ ACH/Bank draft ☐ Other: [Method]
2.2 Card/Account Holder Name: [Name]
2.3 Billing Address: [Address]
2.4 Payment Information (Handle Securely):
Card Number or Bank Account: [____]
Expiration (if card): [MM/YY]
Routing Number (if ACH): [____]
Last 4 digits (recommended): [####]
Card Number or Bank Account: [____]
Expiration (if card): [MM/YY]
Routing Number (if ACH): [____]
Last 4 digits (recommended): [####]
3.1 Start Date: [Start Date]
3.2 Frequency: ☐ Weekly ☐ Biweekly ☐ Monthly ☐ Quarterly ☐ Annually ☐ Other: [Frequency]
3.3 Amount (If Fixed): $[Amount] per billing cycle.
3.4 Amount (If Variable): Based on: [Usage/plan/tier], calculated as: [Description].
3.5 Maximum Charge (Optional for Variable): $[Max Amount] per billing cycle.
3.6 One-Time Setup Fee (Optional): $[Amount] charged on [Date].
4.1 This authorization covers: ☐ Subscription ☐ Membership ☐ Services ☐ Retainer ☐ Installment plan ☐ Other: [Describe].
4.2 Service period (Optional): [Dates/Month].
5.1 If the amount changes, the merchant will provide notice: ☐ [__] days before charge ☐ via email ☐ via invoice ☐ other: [Method].
6.1 Cancellation Method: Customer may cancel by: ☐ Email ☐ Phone ☐ Online portal ☐ Written notice to [Contact].
6.2 Notice Period: Cancellation must be received at least [**] business days before the next scheduled charge.
6.3 Returned Payments/Declines: If a charge fails, merchant may retry [**] times and may charge a returned payment fee of $[__], if allowed.
6.4 Update Payment Info: Customer agrees to keep payment information current.
7.1 I authorize [Merchant Name] to charge my payment method described above according to the schedule and terms in this form.
7.2 I understand I may revoke this authorization by canceling as described in Section 6, subject to any contract terms for services already provided.
Customer/Authorized Payer: [Name]
Date: [Date]
Signature: ___________________________
Merchant Representative (Optional): [Name]
Title/Role: [Title]
Date: [Date]
Signature: ___________________________
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 Recurring Payment Authorization Form is a written permission that allows a business or service provider to charge a customer’s payment method automatically on a set schedule. It is commonly used for subscriptions, memberships, retainers, installment plans, and ongoing services.
It should include: customer name, payment method details, amount and frequency, start date, billing descriptor (optional), what charges are covered, cancellation rules, and how to update payment information. This template includes both fixed-amount and variable-amount options.
Yes, for usage-based or variable billing. If the amount can change, the authorization should clearly state how amounts are calculated and how notice will be given. This template includes a “variable amount” option and a notice section.
Cancellation terms should be written clearly (notice method, timing, and any final charge). This template includes simple cancellation language and a space for a policy link or written terms.
Often yes, depending on local law and the payment processor’s requirements. This template includes a checkbox for e-signature acceptance.
AI Lawyer is an AI-powered assistant that helps you create and customize legal and business document templates online. It guides you through key sections, suggests wording, and explains complex concepts in simple language. AI Lawyer does not replace a licensed attorney or provide legal advice, but helps you prepare better documents faster and more confidently.
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