Dear…

RE: __(Name)__ - __(Reference/Policy)__ __(#)__

I do hereby give authorization to __(name of organization)__ to automatically withdraw monthly __(payments/premiums)__ from my credit card for __(Briefly describe what the payments are for)__, as indicated below:

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Name: ______________________________________________________________

First Middle Last

Address:_____________________________________________________________

Street/Box # City State/Province Zip/Postal Code

Phone Number: ________________________

VISA ___ MasterCard ___ AMEX ___ Discover ___

CARD # ______________________________________________________

Expiry Date: ____/_____

Mo. Year

Monthly Withdrawal Amount: $____________

Authorized Signature: X_________________________ Date: ________________

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I trust you will find all to be in order and thank you for your attention to this matter.

Yours truly,