One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize Chapman Funeral Homes to make a onetime debit to your credit card listed below.

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below, please print:

I _________________________________ authorized Chapman Funeral Homes to charge my

Credit card account indicated below, for $____________ on or after ________________ _______, 20____.

This payment is for the Funeral Services of ___________________________________________________________

Billing Address __________________________ ____ Phone Number __________________________

City, State, Zip_______________________________ E-mail__________________________________

Signature__________________________________________ Date_____________________

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated above. I also authorize a payment of $40.00 shipping cost, if the cremated remains have not been picked up in 30 days from date of death.