Pre-Authorized Payment, Specific Amount
[DATE, ex. Wednesday, June 11, 1998]
[NAME, COMPANY AND ADDRESS, ex.
1234 First Street
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. 15th 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]
[YOUR NAME, ex. Jill Jones]