Credit Card Payment Plan Authorization Form printable pdf download

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Credit Card Payment Plan Authorization Form

You can pay off your balance with a simple automated payment plan. It’s easy to set-up, and your

payments will take care of themselves. Just complete and sign the form below to get started!

Here’s How the Payment Plan Works:

We decide upon a mutually agreeable number of payments and a schedule. You authorize the

regularly scheduled charges to your credit card. A receipt will be emailed for each payment that

includes information on how much you’ve paid off, how much is left, and your next scheduled payment

and date. When the total due is collected, the schedule ends and the authorization is terminated.

Please complete the information below:

Total Due: _________

Payment Frequency: __________________________

# of Payments:

_________

Start Date: __________________________

Payment Amount: _________

I ____________________________ authorize

to charge my account indicated

(full name)

below to discharge the above debt for _____________________________________, using installment

(description of goods/services)

payments in the amount and schedule indicated.

Billing Address ____________________________

Phone# ________________________

City, State, Zip ____________________________

________________________

Account Type:

Visa

MasterCard

AMEX

Discover

Cardholder Name _________________________________________________

Account Number

_____________________________________________

Expiration Date

____________

SIGNATURE

DATE

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined

above. If the above noted payment date(s) fall on a weekend or holiday, I understand that the payment may be executed on the next

business day. I understand that this authorization will remain in effect until the debt is fully discharged or I cancel it in writing which

ever comes first, and I agree to notify the business in writing of any changes in my account information or termination of this

authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not

dispute the payments with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Credit Card Payment Plan Authorization Form

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