Letter to Bank authorizing Bank to periodically pay a varying amount from your account.

Form Outline:

Date
Name of Party Receiving Payment
Address of Party Receiving Payment

Dear Sir or Madam:

You are hereby authorized to...:

Bank:
Bank Transit No: 
Account No: 
Bank Tel. No. Bank Telephone Number
Bank Contact Name of Account Representative

This shall be your...

We enclose...

Yours truly,
Your Name

Banking Forms