Recurring Payment Authorization Form Template

Merchant/Service Provider Name: [Business Name]
[Address]
[Phone] | [Email]
[Website (Optional)]

Customer Name: [Full Name / Business Name]
Account/Invoice Number (Optional): [Number]
Date: [Date]

1. Authorization Type

1.1 Billing Type (Select One):
☐ Fixed amount recurring payments
☐ Variable amount recurring payments (amount may change)

2. Payment Details

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): [####]

3. Schedule and Amount

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. What Charges Are Covered

4.1 This authorization covers: ☐ Subscription ☐ Membership ☐ Services ☐ Retainer ☐ Installment plan ☐ Other: [Describe].
4.2 Service period (Optional): [Dates/Month].

5. Notice of Changes (Optional)

5.1 If the amount changes, the merchant will provide notice: ☐ [__] days before charge ☐ via email ☐ via invoice ☐ other: [Method].

6. Cancellation and Updates

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. Authorization and Acknowledgment

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.

Signatures

Customer/Authorized Payer: [Name]
Date: [Date]
Signature: ___________________________

Merchant Representative (Optional): [Name]
Title/Role: [Title]
Date: [Date]
Signature: ___________________________