Dear…

RE: __(Name)__ - __(Reference/Policy)__ __(#)__ I do hereby give authorization to __(name of organization)__ to automatically withdraw monthly __(payments/premiums)__ from my bank account for __(Briefly describe what the payments are for)__, as indicated below:

********************************************************************

Name:______________________________________________________________

First Middle Last

Address:____________________________________________________________

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

Phone Number: _____________________

Name of Financial Institution:___________________________________________

Address:____________________________________________________________

Street City State/Province Zip/Postal Code

Branch Transit #__________ Institution ID #______ Account #________________ Monthly Withdrawal Amount: $ ___________

Authorized Signature: X ________________________ Date: __________________

********************************************************************* __(For your record information, I have attached a copy of a voided check)__. I trust you will find all to be in order and thank you for your attention to this matter.

Yours truly,