PRE-AUTHORIZED PAYMENT, SPECIFIC AMOUNT

PRE-AUTHORIZED PAYMENT, SPECIFIC AMOUNT

[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. 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]

Sincerely,

[YOUR NAME, ex. Jill Jones]