Date:

To:

From (Tenant's Name):

Rental Property Address:

Bank Name:

Bank Account Number:

Routing Number (if applicable):

Monthly Rent Amount:

Debit Date (e.g., 1st of every month):

I hereby authorize and provide consent to deduct the above-mentioned monthly rent from my bank account automatically each month for the property noted above. I understand that this authorization will remain in effect until I provide written notice of cancellation.