Pre-Authorized Payment_Specific Amount

Letterhead

{{company_name}}

{{company_address}}

{{phone}}

{{email}}

{{website}}

Date

{{date}}

Pre-Authorized Payment Authorization - Specific Amount

To: {{bank_name}}

Bank Address: {{bank_address}}

Account Name: {{account_holder_name}}

Account Number: {{account_number}}

Branch Code: {{branch_code}}

Authorization

I/We, {{company_name}}, hereby authorize {{bank_name}} (hereinafter referred to as 'the Bank') to debit my/our account number {{account_number}} for the specific amount of {{currency}} {{amount}} ({{amount_in_words}}) on a {{frequency}} basis, commencing on {{start_date}}.

Beneficiary Details

Payment is to be made to the following beneficiary:

Beneficiary Name: {{beneficiary_name}}

Beneficiary Bank Name: {{beneficiary_bank_name}}

Beneficiary Account Number: {{beneficiary_account_number}}

Beneficiary Branch Code: {{beneficiary_branch_code}}

Reference for Beneficiary: {{beneficiary_reference}}

Purpose of Payment

The purpose of this recurring payment is {{purpose_of_payment}}.

Cancellation Policy

This authorization will remain in effect until cancelled by me/us in writing. I/We understand that I/we can cancel this authorization by giving {{cancellation_notice_days}} days' written notice to both {{bank_name}} and {{beneficiary_name}}.

Indemnity

I/We undertake to indemnify the Bank against any loss or damage which it may suffer as a result of acting on this authorization.

Contact Information

For any queries regarding this authorization, please contact:

Contact Person: {{contact_person_name}}

Contact Number: {{contact_phone_number}}

Contact Email: {{contact_email_address}}

Signature Block

Signed at {{city}} on this {{day}} day of {{month}}, {{year}}.

_____________________________

Signature of Authorized Signatory 1

Name: {{authorized_signatory_name_1}}

Designation: {{authorized_signatory_designation_1}}

_____________________________

Signature of Authorized Signatory 2 (if applicable)

Name: {{authorized_signatory_name_2}}

Designation: {{authorized_signatory_designation_2}}