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PRE-AUTHORIZED PAYMENT, VARYING AMOUNT

[DATE, ex. Wednesday, June 11, 1998]

[NAME, COMPANY AND ADDRESS, ex.

John Smith

XYZ Bank

1234 First Street

Suite 567

Anycity, Anystate  85245]

Dear [NAME, ex. John Smith],

You are hereby authorized to withdraw from the following account the amount due on our [NATURE OF CHARGES, ex. telephone bill] on a [PERIOD OF PAYMENT, ex. monthly, weekly] basis on the [NUMBER OF DAYS AFTER BILLING DATE, ex. 15^th] day after the billing date:

Bank:                            [BANK NAME AND ADDRESS]

Bank Transit No:            [BANK TRANSIT NO., ex. 4444]

Account No:                  [ACCOUNT NUMBER, ex. 12345678]

Bank Tel. No.                [BANK TELEPHONE NO., ex. (XXX) XXX-XXXX]

Bank Contact                [NAME OF BANK CONTACT, ex. Susan Smith, Manager]

This shall be your good and sufficient authority for so doing.

We enclose an unsigned check from the account marked “VOID”.

[NOTE: IF MORE THAN ON SIGNATURE IS REQUIRED ON ACCOUNT, MAKE SURE BOTH BANK SIGNING OFFICERS SIGN LETTER]

Sincerely,

[YOUR NAME, ex. Jill Jones]