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

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,