Letter to Service Provider to Cancel Direct Debit - Word & PDF Template Form

________
________
Email: ________
Phone: ________

________
________

Date: ________

RE: Cancellation of Direct Debit Request (Direct Debit Authority)

To whom it may concern,

I, ________, write to give you formal notice that I wish to cancel the Direct Debit Request (the Direct Debit Authority) that I previously established with your organisation. The relevant details of the arrangement I am cancelling are set out below.

§ 1  –  Details of the Direct Debit Arrangement

1. Account holder name: ________
2. Customer / payment reference number: ________
3. Financial institution (bank) name: ________
4. BSB number: ________
5. Account number (last four digits): ________
6. Debit amount: $________ (________) per ________
7. Purpose of payments: ________
8. Date the Direct Debit Authority commenced: ________

§ 2  –  Cancellation

1. I hereby cancel, revoke and withdraw the Direct Debit Authority described in § 1 with effect from ________, or otherwise with immediate effect on the date of this letter, whichever is the later.
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3. From the effective date of cancellation, you are no longer authorised to draw, debit or otherwise charge any amount from the account identified in § 1 under this Direct Debit Authority.

§ 3  –  Requests and Acknowledgements

1. Please process this cancellation without delay and confirm to me in writing, at the address or email shown above, that the Direct Debit Authority has been cancelled and that no further amounts will be debited from my account under it.
2. If any amount is debited from my account after the effective date of this cancellation, I require that it be refunded to me in full promptly upon notification.
3. Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor in reprehenderit.
4. I request that you treat my personal and banking information in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles.
5. Please direct any queries concerning this cancellation to me using the contact details set out at the top of this letter.

Kindly acknowledge receipt of this letter.

Yours faithfully,

________
Signature: ________
Dated: ________