Payment Authorization Form

Payment Authorization Form

Authorize recurring payments for accounting services. Please review, complete, and sign this form to provide your consent.
Authorization Statement
You authorize Dietz Bookkeeping regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your credit card statement. 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.

I authorize Company Name to charge my credit card indicated below for accounting services on the 1st of each month.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Bryan Dietz, at bryanD@dietzbookkeeping.com 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 1st of the month falls on a weekend or holiday, I understand that the payment may be executed on the next business day. I acknowledge that the origination of credit card transactions to my account must comply with the provisions of US law. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.
Client Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Card Type

Other
Cardholder Name (as shown on card)
Authorized Monthly Amount (USD)
Date of Authorization

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Signature
Should be Empty: