Who may legally sign the authority?

The payee or an authorized officer, agent, or legal representative may sign, provided the signer has documented authority (corporate resolution, power of attorney). Verify capacity before acceptance to avoid disputes; include title and reference to authorization source in the signature block.

Is electronic signing valid for this form?

Yes. Electronic signatures satisfy ESIGN (15 U.S.C. ch. 96) and UETA where adopted, provided intent and consent are demonstrable and records are retained. Use required consumer disclosures for covered consumer transactions.

When is notarization or witnessing required?

Notarization or witness requirements depend on state law and the payment type. Some states require notarization for documents affecting real property or certain POAs. Check state notary rules and consider RON if permitted.

How do I revoke the authority?

Revoke by delivering written notice to payer and any authorized recipient; follow any notice period in the document. For electronic records, deliver a signed revocation and retain proof of delivery. Verify payer acknowledgment to stop further payments.

Which supporting documents should be attached?

Attach identification, tax forms (W-9) for payee, bank account verification, invoice or contract references, and any corporate resolution or POA proving signer authority. These documents reduce processing delays and satisfy payer due diligence.

What steps follow if payment is misdirected?

Notify payer immediately, demand return or recredit, and document communications. If funds are unrecoverable, consider legal remedies; preserve audit trails and consult counsel. Criminal misdirection may warrant law enforcement referral.

Electronic Signature
Templates
Legal
Authority to Receive Payment

Authority to Receive Payment

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

AUTHORITY TO RECEIVE PAYMENT

This Authority to Receive Payment (the Authority) is entered into as of by and between Principal Name: (Principal) and Authorized Recipient Name: .

RECITALS

WHEREAS, Principal is entitled to receive payments, fees, refunds or other disbursements (Payments) arising from or in connection with services, contracts, accounts, claims or invoices described in this Authority; and

WHEREAS, Principal desires to authorize the Authorized Recipient to receive, endorse and otherwise collect such Payments from the parties identified herein or from any payer notified in accordance with this Authority; and

WHEREAS, Authorized Recipient is willing to accept such authority subject to the terms and conditions of this Authority.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. AUTHORIZATION

Principal hereby appoints and authorizes Authorized Recipient to receive, open, endorse, deposit, and otherwise collect all Payments payable to Principal from the payer identified below (Payer) with respect to the matters described in Section 2. This authorization includes the right to execute endorsements, receipts, releases, or other instruments necessary to effect collection of such Payments.

Payer Name

2. PAYMENTS AND SCOPE

Authorized Recipient is authorized to receive Payments described as:

The authority granted by this Authority expressly includes collection by check, electronic funds transfer, wire transfer, or other commercially accepted method. Payments may be directed to the Authorized Recipient's account set forth below, and Principal authorizes payers to rely on this designation until revocation is delivered in accordance with Section 5.

Bank Name for Deposit (if applicable)

Routing Number

Account Number

Account Type

3. LIMITATIONS; AMOUNTS; RECORDS

Principal authorizes collection only of Payments described in Section 2 and not for any unrelated debts or obligations unless expressly authorized in writing. Principal may specify limits on amounts or specific invoices below; absent such specification, Authorized Recipient's authority extends to any Payment otherwise payable to Principal.

Maximum Amount Authorized (if any) Invoice, Account or Reference Identifiers (optional)

Authorized Recipient shall keep accurate books and records of all Payments received under this Authority and shall make such records available to Principal upon reasonable request.

4. TERM; REVOCATION

This Authority is effective as of the effective date set forth above and shall continue in full force and effect until:

terminated by written notice from Principal delivered to Authorized Recipient and the Payer in accordance with Section 6; or
terminated on , if specified by Principal.

5. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that: (a) it has the full right, power and authority to enter into this Authority and to perform its obligations hereunder; (b) the execution and delivery of this Authority has been duly authorized; and (c) this Authority constitutes a legal, valid and binding obligation enforceable against it in accordance with its terms.

6. INDEMNIFICATION; LIMITATION OF LIABILITY

Principal shall indemnify, defend and hold harmless Authorized Recipient and any payer acting in reasonable reliance upon this Authority from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorney's fees) arising from or related to the Authorized Recipient's collection of Payments pursuant to this Authority, except to the extent caused by Authorized Recipient's willful misconduct or gross negligence.

7. NOTICES

Any notice, demand or other communication required or permitted under this Authority shall be in writing and delivered to the addresses set forth below (or such other address as either party shall designate by notice in writing).

Principal Address for Notices Authorized Recipient Address for Notices

8. GOVERNING LAW; DISPUTE RESOLUTION

This Authority shall be governed by and construed in accordance with the laws of the State of without regard to its conflicts of law principles. Any dispute arising out of or relating to this Authority shall be resolved by binding arbitration if the parties mutually agree in writing; otherwise, the parties may seek any available legal or equitable relief in a court of competent jurisdiction.

9. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT

This Authority constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Authority is held to be invalid or unenforceable, the remainder of this Authority shall remain in full force and effect. This Authority may be amended only by a written instrument signed by both parties.

10. COUNTERPARTS; AUTHORIZATION TO RELY

This Authority may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Any payer or financial institution may rely upon a copy or facsimile of this Authority and shall be fully protected in making payments in reliance hereon until notified in writing of revocation.

CERTIFICATION

By signing below, Principal certifies that the information provided in this Authority is true and correct, that the person executing this Authority on behalf of each signing party is authorized to do so, and that Principal accepts responsibility for any payments made in good faith to Authorized Recipient pursuant to this Authority until such time as revocation is provided in writing.

Additional Instructions to Payer or Special Conditions (optional)

ENTITY TYPE

Principal Entity Type: Individual Corporation Limited Liability Company Partnership

Authorized Recipient Entity Type: Individual Corporation Limited Liability Company Partnership

Principal:

By:

Date:

Authorized Recipient:

By:

Date:

What an Authority to Receive Payment Is and when it applies

An Authority to Receive Payment is a written authorization that permits a designated person or entity to accept specified payments on behalf of a payee. It identifies the payer, the payee, the authorized recipient, payment types and amounts, effective dates, and any limitations or instructions. Organizations use it to route settlements, vendor reimbursements, insurance proceeds, or government disbursements without requiring the payee to be present. When executed correctly, it creates a clear record of consent and can be completed electronically under the ESIGN Act and UETA when both parties consent to e-signatures.

Why a clear payment authorization matters

Using an Authority to Receive Payment clarifies payment routing, reduces payment delays, and creates a verifiable record of consent for auditors and payers. It limits disputes over receipt, supports compliance with financial controls, and can be executed electronically under ESIGN and UETA.

Who typically prepares and signs this authority

Companies, independent contractors, healthcare providers, and financial officers commonly prepare this form to delegate payment receipt and simplify transactional workflows.

Real estate agents and property managers handling security deposit or settlement distributions.
Healthcare billing departments assigning third-party collection or insurance payment routing.
Accounts payable teams delegating vendor reimbursements or third-party invoice settlements.

Choose the signer with legal authority and document internal approval to avoid disputes; maintain records for audit and tax reporting purposes.

Essential elements of a professional Authority to Receive Payment

A professional Authority to Receive Payment is concise, explicit about scope, timestamps payments, and records consent. Clear formatting reduces disputes and eases audit verification.

Scope

Define precisely which payments the designee may receive, whether single transaction, recurring payments, or all funds of a specified type; include limits and conditions to prevent unintended authority beyond the payee's consent.

Amounts

State maximum payment amounts, thresholds requiring payee approval, and currency to avoid processing errors or bank rejections; tie amounts to invoice numbers or contract references where possible for traceability.

Instructions

Specify payment method (ACH, check, wire), account details if applicable, remittance instructions, and any holdback or conditional release criteria so banks and payers can process without follow-up.

Identification

Include government ID numbers, taxpayer identification, corporate identifiers, and bank routing verification for recipient confirmation; accurate identifiers reduce KYC friction and prevent misapplied funds or fraudulent diversion.

Signatures

Provide signature block for payee and authorized representative, include printed names, titles, and dates; note whether third-party signature suffices and whether notarization or witness signatures are required.

Retention

State how long records of the authorization and related remittance advices will be retained, where originals are stored, and who may access them for audit or compliance inquiries.

Required information to include on the form

Payer Information: Name, address, and taxpayer identification.

Payee Details: Full legal name and contact info.

Authorized Recipient: Name, company, and relationship to payee.

Payment Terms: Amount, currency, method, and schedule.

Effective Dates: Start date and optional end date.

Signature Block: Signatures, dates, and signer titles.

Step-by-step: complete and deliver the authority

Follow these steps to complete and deliver an Authority to Receive Payment accurately and securely, whether on paper or electronically.

01

Prepare Document: Gather payee, payer, and recipient details; confirm amounts.
02

Complete Fields: Fill required fields and double-check identifiers.
03

Authenticate Signers: Obtain signatures, witness or notary as required.
04

Distribute Copies: Send signed copies to payer, recipient, and retain one.

Where to send or file the executed authority

Common submission paths depend on payer type: internal finance, insurance claims department, third-party settlement agent, or government disbursing office; choose the appropriate recipient.

Accounts Payable: Send signed authority with invoice references to AP for processing.
Insurance Claims: Attach authorization to claim forms and provider invoices.
Third-Party Agent: Provide agent with authorization and recipient banking details.
Government Agency: Follow agency instructions for submission and retain proof.

Technical considerations for e-signing and distribution

Use an e-sign platform that provides TLS 1.2/1.3 encryption in transit, AES-256 at rest, detailed audit logs, and optional multi-factor signer authentication.

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest.
Integrations: Connectors for Salesforce, NetSuite, Google Workspace, and Microsoft 365.
File Formats: Accepts PDF, DOCX, HTML, and Excel forms.

Timing and processing expectations to avoid delays

Timing for using an Authority to Receive Payment depends on payer processing cycles; initiate before scheduled payment dates and allow time for verification and bank processing.

When to submit before payment:

Submit at least 5 business days before scheduled transfers.

Insurance claim authorization and routing timelines:

Follow insurer deadlines; submit with claim forms to avoid denial.

Vendor reimbursement processing and approval window:

Allow one to three billing cycles for reconciliation.

Bank account verification and settlement timing:

ACH verification may take one to two business days.

Revocation notice timing and effective dates:

Revocation typically effective upon receipt; allow payer processing window.

Common mistakes to avoid when preparing the authority

Using an inaccurate payee name or TIN causes bank rejections, triggers backup withholding, and creates IRS information return penalties under IRC §6721.
Omitting payment method or account details forces manual follow-up, delays disbursement, and increases risk of misapplied funds or fraudulent redirection.
Granting broad authority without dollar caps or scope can enable unintended transfers; include explicit limits and approval thresholds to protect payee interests.
Accepting weak authentication or skipping ESIGN consumer disclosures for consumer-facing payments may render the electronic authorization harder to enforce in disputes.

Key penalties and legal risks to watch

1099 Filing Penalties: IRC §6721: $60–$330 per incorrect return.

Intentional Disregard: $660+ per form; no cap.

Backup Withholding: 24% withholding required for missing TIN.

I-9 Violations: Civil fines $281–$2,789 per violation.

Contract Disputes: Unauthorized receipts risk restitution and litigation.

Fraud Exposure: Misapplied funds may trigger criminal liability.

Vendor pricing and feature snapshot for document signing

Compare starting prices, trial options, bulk send, audit trail, and HIPAA compliance across common e-sign vendors; signNow appears first in the comparison below.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about Authorities to Receive Payment

Answers to common questions about completing, signing, and revoking an Authority to Receive Payment along with digital signing considerations.

Need help? Contact support

Who may legally sign the authority?
The payee or an authorized officer, agent, or legal representative may sign, provided the signer has documented authority (corporate resolution, power of attorney). Verify capacity before acceptance to avoid disputes; include title and reference to authorization source in the signature block.
Is electronic signing valid for this form?
Yes. Electronic signatures satisfy ESIGN (15 U.S.C. ch. 96) and UETA where adopted, provided intent and consent are demonstrable and records are retained. Use required consumer disclosures for covered consumer transactions.
When is notarization or witnessing required?
Notarization or witness requirements depend on state law and the payment type. Some states require notarization for documents affecting real property or certain POAs. Check state notary rules and consider RON if permitted.
How do I revoke the authority?
Revoke by delivering written notice to payer and any authorized recipient; follow any notice period in the document. For electronic records, deliver a signed revocation and retain proof of delivery. Verify payer acknowledgment to stop further payments.
Which supporting documents should be attached?
Attach identification, tax forms (W-9) for payee, bank account verification, invoice or contract references, and any corporate resolution or POA proving signer authority. These documents reduce processing delays and satisfy payer due diligence.
What steps follow if payment is misdirected?
Notify payer immediately, demand return or recredit, and document communications. If funds are unrecoverable, consider legal remedies; preserve audit trails and consult counsel. Criminal misdirection may warrant law enforcement referral.

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