Date:

Dear Sir or Madam:

You are authorized and directed to debit our Account, named ____________, with our Account number: ______________, for $ ___________ for a one time payment, payable payable to: _________________ (Name), at _____________ (Bank), with account number ________________ and ABA Routing Number _________________. Please charge our account any fees to accomplish this transaction.

This shall be your good and sufficient authority for doing so.

Best regards,

_____________
Authorized Signer of Account
cc Recipient of debit

Debit Your Account, One Time Authorization
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. Debiting accounts has become a quick way to transfer funds to pay obligations and can bring advantages to both parties. Be sure the signer is an authorized signer of the account being debited. You are advised to use the same form, signed by the same person, to expedite this at your Bank. After they get to know you, the Bank will often accept a faxed notice versus a hand delivered one. You do not need a witness since you do not need one for a normal bank check.

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