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Recurring Payment Authorization Form Template

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Recurring Payment Authorization Form Template

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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: ___________________________

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Learn more about

Recurring 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.

RECURRING PAYMENT AUTHORIZATION FORM TEMPLATE FAQ


What is a recurring payment authorization form?

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.


What should the form include?

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.


Can the amount change each billing cycle?

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.


How can the customer cancel?

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.


Is an electronic signature allowed?

Often yes, depending on local law and the payment processor’s requirements. This template includes a checkbox for e-signature acceptance.


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