EXAMPLE AUTHORIZATION FORMS & SCRIPTS

3.1 Single Payment Examples

3.1.1 EXAMPLE OF PPD (WRITTEN) AUTHORIZATION FOR A SINGLE PAYMENT

Company Name:___________________________________________________________________________________________________
I hereby authorize (Business or Entity Name) , to initiate an electronic single entry debit/credit from my
account with the Financial Institution indicated below in the amount of $___________ for the purpose of
(Description of the purpose of the payments) . Furthermore, I assert that I am the owner or an authorized
signer of this bank account.
The effective date of the payment will occur on or after (Date) .
Type of Account: q Checking Account q Savings Account
Financial Institution Name:_________________________________________________________________________________________
Financial Institute City and State: __________________________________________________________________________________
Name on the Account: ______________________________________________________________________________________________
Transit/ABA/Routing No. ______________________________________

Account No._______________________________________
Note: You may wish to request a voided check in order to verify that the routing number and account
number above are accurate and that the bank account is, in fact, in the name of the customer.
Please sign and date this authorization below:
Your Signature_________________________________________________ Today’s Date_____________________________________
If you have any questions or concerns in regards to this payment, or you need to revoke this authorization,
please call (Customer Service Phone Number) during the following business hours: (Business Hours) .

3.1.1.1 PROOF OF AUTHORIZATION:

  • A copy of the signed authorization.

3.1.2 EXAMPLE OF A TEL (VERBAL) AUTHORIZATION FOR A SINGLE PAYMENT

“Today is __________ and I am now going to take your payment information. For verification and compliance
purposes, I will be recording this portion of our call; do I have your permission to record your payment
authorization?”
Can you repeat your name as it appears on the bank account from which we will be withdrawing your
payments?
May I have the name of your bank?
May I have the bank routing number?
May I have the bank account number?
The amount of the payment you are authorizing today is ___________.
To confirm, on today’s date __________, you are authorizing (Company Name) to initiate a single entry debit
from the (Name of Bank) bank account number _______________________, routing number _____________________,
and that you (Name of Customer) are an owner of this account. The payment is being initiated today
(Month and Day) and will have an effective date and appear as a withdrawal from your account on (the
following business banking day / Month and Day) .
Do I have your permission to initiate this payment?
If you have any questions or wish to revoke this authorization, please contact us at _________________. Our
customer service hours are (Hours and Days of Operation) .
Upon the conclusion of our call, I am required to send you notification of your payment for the purpose of
confirming your payment authorization. If you wish to receive this notification electronically, please provide
your email address.
Can you repeat that address again so I can ensure its accuracy? If you do not receive this email shortly after
we end this call, please call back at ________________ and the confirmation will be resent.
Thank you _________________ for your order (and/or payment).

3.1.3 EXAMPLE VERIFICATION EMAIL OR MAILED AUTHORIZATION FOR A SINGLE PAYMENT

(Verification email or mailed confirmation letter should be sent out when an authorization is for a
single payment. This is strongly recommended as best practice).

Letter should summarize the basic terms of the transaction to include the amount and date the payment
was authorized and effective date of the payment, the purpose of the payment, a means for revoking the
payment, and any other important terms and conditions in which good business practices would dictate
disclosure.
The name of the Company or Entity should be at the header of the email, or if mailed, presented on a
Company Letterhead.
Payer’s Name
Today’s Date
Thank you for your order (and/or payment).
Please accept this (Email/Letter) as confirmation of the electronic single entry debit which you (Customer
Name) , the account holder, has previously authorized on (Date of Authorization) to be withdrawn from
the (Name of Bank) bank ending in (last four digits of the bank account number) in the amount of (Dollar
Amount) for the payment of (Description of the Product/Services or the purpose of the payment) to
(Company or Entity Name) .
The effective date of the payment will be (Date) or the following banking day.
If you have received this notification in error, the information provided herein is incorrect, or you wish to
revoke this authorization, please call us at (Customer Service Number) , or email us at (Customer Service
Email) .
(Any additional, appropriate information or disclosures).

3.1.3.1 Proof of Authorization:

  • A digital recording of the verbal authorization and/or a copy of the original email or confirmation letter.

  • If providing an email copy, the email should be date and time-stamped, and show the full email address
    of the Payer.

3.1.4 EXAMPLE OF A WEB (ONLINE) AUTHORIZATION FOR A SINGLE PAYMENT

Text similar to that provided in the example below should appear adjacent to or above the tab on the
payment page where the customer completes the transaction:
By clicking on “Submit,” I hereby authorize (Business or Entity Name) to initiate an electronic single debit
entry from the above indicated bank account in the amount entered (or provided) on this page. I understand
that if this transaction is submitted after 6:00 PM Eastern Standard Time, it will have an effective date of no
sooner than the next business-banking day and will show as a withdrawal from my account on that date. If
I wish to revoke this authorization, and revoke this payment, or the amount withdrawn from my account is
different than the amount authorized herein, I may call (Customer Service Number) during the following
business hours (Business Days and Hours) . Furthermore, I assert that I am the owner or an authorized
signer of the bank account provided.

3.2 Recurring Payment Examples

3.2.1 EXAMPLE OF A PPD (WRITTEN) AUTHORIZATION FOR A SERIES OF RECURRING PAYMENTS OR PAYMENTS AS DUE

I hereby authorize (Business or Entity Name) to initiate recurring debit/credit entries from my account with
the Financial Institution indicated below in regards to (Description of the purpose of the payments) or
other charges as they become due and payable under the terms and conditions of the attached
(Agreement or Contract) .
(Total of Payments) in the amount of (Dollar Amount) will be withdrawn from my account on the (Day of
the Month) . If that day falls on a weekend or bank holiday, the withdrawal shall occur on the next business
banking day. The effective date of the first payment is (Date) , followed by (Remaining Payments) .
Type of Account: q Checking Account q Savings Account
Financial Institution Name:_________________________________________________________________________________________
Financial Institute City and State: __________________________________________________________________________________
Name on the Account: ______________________________________________________________________________________________
Transit/ABA/Routing No. ______________________________________

Account No._______________________________________
Note: You may wish to request a voided check in order to verify that the routing number and account
number above are accurate and that the bank account is, in fact, in the name of the customer.
Please sign and date this authorization below:
Your Signature_________________________________________________ Today’s Date_____________________________________
If you should need to notify us of your intent to cancel and/or revoke this authorization, you must contact us
(# of days/weeks/months) prior to the questioned debit being initiated. Please call (phone number) or
email at (email address) - (open business days) from (open business hours) .

3.2.1.1 Proof of Authorization

  • A copy of the signed authorization.

3.2.2 EXAMPLE OF A TEL (VERBAL) AUTHORIZATION FOR A SERIES OF RECURRING PAYMENTS

“Today is _________ and I’m now going to take your payment information for _________. For verification and
compliance purposes, I will be recording this portion of our call; do I have your permission to record your
payment authorization?”
Can you repeat your name as it appears on the bank account from which we will be debiting your
payments?
May I have the name of your bank?
May I have the bank routing number?
May I have the bank account number?
The amount of the (Monthly, Weekly, Quarterly) payment you are authorizing today (Recite Today’s Date)
is $__________________.
The first payment will be withdrawn from your bank on (Month / Day) . Then, (Number) subsequent
payments on the (Day of each Month or other specified cycle) for the duration of this authorization and
term of your (Agreement, Subscription, Service Plan, Payment Plan, etc.) .
To confirm, on today’s date _________, you are authorizing (Company Name) to initiate a recurring debit from
the (Name of Bank) bank account number ______________, routing number ______________, and that you (Name
of Customer) are an owner of this account.
Do I have permission to initiate these payments?
If you have any questions or wish to revoke this authorization, please contact us at __________________. Our
customer service hours are (Hours and Days of Operation) .
Upon the conclusion of our call, I am required to send you notification of your payment for the purpose of
confirming your payment authorization. If you wish to receive this notification electronically, please provide
your email address. Can you repeat that address again so I can ensure its accuracy? If you do not receive this
email shortly after we end this call, please call back at ___________ and the confirmation will be resent.

3.2.3 EXAMPLE VERIFICATION EMAIL IF AUTHORIZATION IS FOR A SERIES OF RECURRING PAYMENTS

(Verification email or mailed confirmation letter is required to be sent out in addition to recorded
oral authorization for a recurring payment)

Letter should summarize the basic terms of the transaction to include the amount and date the payment
was authorized and effective date of the payment, the purpose of the payment, a means for revoking the
payment, and any other important terms and conditions in which good business practices would dictate
disclosure.
The name of the Company or Entity should be at the header of the email, or if mailed, presented on a
Company Letterhead.
Payer’s Name
Today’s Date
Thank you for your order (and/or payment).
Please accept this email/letter as confirmation that on today’s date _______, you, ____________, have authorized
us, _________________, to electronically debit recurring payments from the bank account provided ending in ****,
from ___________ Bank as payment for (Description of Product / Service or the purpose of the payment) .
The effective date of your first payment is (Date) followed by (Number of Payments) or (until your service /
subscription / membership is cancelled) . These payments will be in the amount $ _______ each, and will be
withdrawn from your bank account on the _____ of each ______ until you notify us of your intent to cancel and/ or revoke this authorization.
If you have questions regarding this debit, please call us at (Customer Service Number) or email us
at (Customer Service Email) during (Hours of Operation). (Any additional, appropriate information or
disclosures).

3.2.3.1 Proof of Authorization

  • A digital recording of the verbal authorization and/or a copy of the original email or confirmation letter.

  • If an email copy, the email should be date and time-stamped, and show the full email address of the
    Payer. If a letter is provided, it should show the mailing address of the Payer.

3.2.4 EXAMPLE OF AN ONLINE AUTHORIZATION FOR A SERIES OF RECURRING PAYMENTS

By clicking “Submit,” I hereby authorize (Business Name or Entity) to initiate electronic recurring
withdrawals from the indicated bank account for payments in the amount of (Amount) (or as they
become due and payable under the terms and conditions of the agreement) and as described herein.
The first payment will be withdrawn from your bank on (Month/Day) or (the following business banking
day) , then, (Number) subsequent payments on the (Day of each Month or other specified cycle) for the
duration of this authorization and term of your (Agreement, Subscription, Service Plan, Payment Plan, etc.) .
If you wish to revoke this authorization and cancel this payment, or the amount withdrawn from my account
is different than the amount authorized herein, I may call (Customer Service Number) during the following
business hours (Business Days and Hours) . Furthermore, I assert that I am the owner or an authorized
signer of the bank account provided.
It is strongly recommended that your web payment application dispatch an email confirmation to the
Customer. Recurring email confirmation must note the terms listed above.

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