Authorization to Creditor to Charge Account for Specific Amount Each Period

[DATE, ex. Wednesday, June 11, 1998] 

[NAME, COMPANY AND ADDRESS, ex.
John Smith
XYZ Bank
1234 First Street
Suite 567
Anycity, Anystate  85245] 

Dear [NAME, ex. John Smith],

You are hereby authorized to withdraw from the following account the amount of [AMOUNT OF PERIODIC DEBIT, ex. $4,299.48] on a [PERIOD OF PAYMENT, ex. monthly, weekly] basis on the [BILLING DATE, ex. 15^th day of each month]: 

Bank:                     [BANK NAME AND ADDRESS]

Bank Transit No:      [BANK TRANSIT NO., ex. 4444]

Account No:             [ACCOUNT NUMBER, ex. 12345678]

Bank Tel. No.           [BANK TELEPHONE NO., ex. (XXX) XXX-XXXX]

Bank Contact           [NAME OF BANK CONTACT, ex. Susan Smith, Manager]

This shall be your good and sufficient authority for so doing. 

We enclose an unsigned check from the account marked "VOID". 

[NOTE: IF MORE THAN ON SIGNATURE IS REQUIRED ON ACCOUNT, MAKE SURE BOTH BANK SIGNING OFFICERS SIGN LETTER]

Sincerely,

[YOUR NAME, ex. Jill Jones]