Authorization to Debit Account

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Date

{{date}}

To Whom It May Concern

**Subject: Authorization to Debit Account**

Account Holder Details

Account Holder Name: {{account_holder_name}}

Physical Address: {{account_holder_address}}

Contact Number: {{account_holder_phone}}

Email Address: {{account_holder_email}}

Bank Account Details

Bank Name: {{bank_name}}

Branch Name: {{bank_branch_name}}

Account Name: {{bank_account_name}}

Account Number: {{bank_account_number}}

Account Type: {{bank_account_type}} (e.g., Cheque/Current, Savings)

Authorization

I/We, the undersigned, {{account_holder_name}}, hereby authorize {{recipient_name}} (hereinafter referred to as 'the Beneficiary') to debit my/our bank account specified above for the amount(s) and purpose(s) detailed below.

This authorization covers:

{{payment_type}}: (e.g., One-time payment, Monthly recurring payment, Quarterly recurring payment)

Amount: {{currency}} {{amount}}

Payment Reference: {{payment_reference}}

Purpose of Payment: {{payment_purpose}}

For recurring payments, this authorization will remain in effect until cancelled in writing by me/us, with {{notice_period}} days' notice to the Beneficiary. For one-time payments, this authorization is valid for a single transaction.

Conditions of Authorization

1. I/We understand that if any debit is returned unpaid due to insufficient funds or any other reason, the Beneficiary may charge a reasonable administrative fee.

2. I/We agree to ensure that sufficient cleared funds are available in the account on the due date of each debit.

3. I/We have the right to cancel this authorization at any time by providing written notice to the Beneficiary, subject to the agreed notice period.

4. I/We confirm that I am/we are the lawful holder(s) of the specified bank account and have the authority to grant this authorization.

5. I/We acknowledge that this authorization does not negate any other terms and conditions governing my/our account with the financial institution.

Declaration

I/We declare that all information provided in this authorization is true and correct.

Signature Block

_____________________________

Signature of Account Holder

Name: {{account_holder_name}}

Date: {{signature_date}}

_____________________________

Signature of Second Account Holder (if applicable)

Name: {{second_account_holder_name}}

Date: {{second_signature_date}}