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This document is a client credit card authorization form for a law firm. It allows clients to initially pay balances due and authorize future monthly payments to be automatically charged to their credit card. Key details include: clients can opt to pay the current balance or set up recurring monthly payments, payments are considered late after a specified date and incur late fees, payment for services are non-refundable with potential refunds of unused funds within a set number of days. The form collects clients' payment information including card number, expiration date and security code.

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kinyas.alexander
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190 views1 page

CC Form

This document is a client credit card authorization form for a law firm. It allows clients to initially pay balances due and authorize future monthly payments to be automatically charged to their credit card. Key details include: clients can opt to pay the current balance or set up recurring monthly payments, payments are considered late after a specified date and incur late fees, payment for services are non-refundable with potential refunds of unused funds within a set number of days. The form collects clients' payment information including card number, expiration date and security code.

Uploaded by

kinyas.alexander
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Firm Name

Firm Address, City, State, & Zip


Firm Phone & Email

Client Credit Card Authorization Form

In an effort to better serve our clients and simplify your billing experience, our firm offers credit card acceptance for your convenience.

ONE/FIRST TIME PAYMENT:


______ I hereby authorize ______________________________________ to charge the balance currently due for
(Initial)
the amount of $__________________________.

FUTURE PAYMENTS:
______
(Initial)
I hereby authorize ______________________________________ to charge the balance due each month.
Payment will be processed on the _______ each month for prior month fees.
CHARGE POLICY

POLICIES:
______ Payment is considered late after the ______ of the month. Any balance will be charged to the card on file. In
(Initial)
addition, a late fee will be assessed in the amount of $________.

______ Payment made for services delivered by this firm are non-refundable.
(Initial)

______ In the case of retained services, any unused funds will be refunded to the card on file within _______ days
(Initial)
of ____________________.

______ Being the authorized cardholder or the Corporate Officer, by signing above I understand and agree to the
(Initial)
terms set forth in this agreement, agree to pay, and specifically authorize to charge my credit card for the
services provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid
credit card upon request, to be charged for the payment of any outstanding balances owed.

Client Name: _________________________________________________________________________

Client Billing Address: _________________________________________________________________________


PAYMENT INFORMATION

_________________________________________________________________________

Type of Card:

Card Number: _________________________________________________________________________


ENCRYPTED IN LAWPAY'S ELECTRONIC CARD VAULT - _ _ _ _ (last 4 digits of card)*
* Per PCI Compliance guidelines, the last 4 digits may be recorded for verification purposes

Expiration Date: ____________________________


ON FILE Security Code: _________________________________
ON FILE

The undersigned guarantees performance of the financial provisions of this agreement.

Card Holder Name: _________________________________________________________________________


Signature of Card Holder: _____________________________________ Date: __________________________

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