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1/28/2011

PRE-AUTHORIZED PAYMENT- VARYING AMOUNT

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. 15th] 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,