Pre-Authorized Payment Specific Amount Template

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PRE-AUTHORIZED PAYMENT SPECIFIC AMOUNT

[DATE]

Dear [RECIPIENT NAME],

This letter is to formally notify you that we are authorizing [COMPANY NAME] to withdraw an amount of $[NUMBER] for a period of [NUMBER 1] months from [START DATE] to [END DATE] . This amount shall be withdrawn every [NUMBER 2] of the month on a [PERIOD] basis until, upon reaching a mutual agreement, the decision to cease your services will be met.

Enclosed within this letter is a blank check taken from the bank account labeled [TITLE]. Also, this letter serves as your authority to allow aforementioned company to carry out [HIS/HER] transactions with the bank account below:

Bank:           [DETAIL]
Bank Transit No:   [NUMBER 3]
Account No:       [NUMBER 4]
Bank Tel. No.       [NUMBER 5]
Bank Contact       [DETAIL 1]

Thank you very much for your cooperation. Feel free to reach us at [PHONE NUMBER] or email us at [EMAIL ID].

Regards,

[YOUR SIGNATURE]

[YOUR NAME]