Fillable Recurring Payment Authorization Form With Credit Card printable pdf download

Recurring Payment Authorization Form

Company Name:

____________________________

Street Address: _________________________

City, State, Zip Code: _________________________

Phone Number: _________________________

Schedule your payment to be automatically deducted from your bank account, or charged to your Visa,

MasterCard, American Express or Discover Card. Just complete and sign this form to get started!

Recurring Payments Will Make Your Life Easier:

It’s convenient (saving you time and postage)

•

Your payment is always on time (even if you’re out of town), eliminating late charges

•

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or credit card. You will

be charged the amount indicated below each billing period. A receipt for each payment will be

emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that

no prior-notification will be provided unless the date or amount changes, in which case you will receive

notice from us at least 10 days prior to the payment being collected.

Please complete the information below:

I ____________________________ authorize ___________________ to charge my credit card

(full name)

(insert business name)

indicated below for ________ on the ________ of each ___________________ for payment of my

(insert $)

(day or date)

(frequency)

___________________.

(insert type of bill)

Billing Address ____________________________

Phone# ________________________

City, State, Zip ____________________________

Email ________________________

Checking/ Savings Account

Credit Card

Visa

MasterCard

Checking

Savings

Name on Acct

____________________

Amex

Discover

Bank Name

____________________

Cardholder Name _________________________

Account Number ____________________

Account Number

_________________________

Bank Routing #

____________________

Exp. Date

____________

Bank City/State

____________________

CVV (3 digit number on back of card) ______

SIGNATURE

DATE

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify ______________ (business name) in writing of

any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment

dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings

account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted

periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that ______________

(business name) may at its discretion attempt to process the charge again within 30 days, and agree to an additional $__________ charge for each

attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of

ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and

will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this

authorization form.

Recurring Payment Authorization Form With Credit Card

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