Debit Your Account, One Time Authorization

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