Direct Debit Form

Instruction your Bank or Building Society to pay by Direct Debit.

Please fill in the whole form including official use box using a ball point pen and send to:

Doug Smith

Canasta Hotel

288 Promenade

Blackpool

FY1 2EY

Originator's Identification Number

Please pay Mr D Smith the sum of £9 per week. This being comprised of approximately 3 days winnings at golf. Please pay this until either party cancels the agreement. Please start this immediately and make further payments every Friday.

Thank you

Mr T Large

Name(s) of Account Holder(s)

Bank or Building Society Account Number

Branch Sort Code

Instruction to your Bank or Building Society

Please pay Doug Smith Direct Debits from the account detailed in this Instruction Subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Doug Smith and if so, details will be passed electronically to my Bank / Building Society.

Signature

Date

Name and full postal address of your Bank or Building Society

To the Manager - Bank / Building Society

Address

Postcode

Reference Number

Banks and Building Societies may not accept Direct Debit Instructions from some types of accounts

This guarantee should be detached and retained by the Payer

The Direct Debit Guarantee

This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme. The efficiency and security of the scheme is monitored and protected by your own Bank or Building Society.

If the amounts to be paid or the payment dates change Doug Smith will notify you 10 working days in advance of your account being debited or as otherwise agreed.

If an error is made by Doug Smith or your Bank or Building Society, you are guaranteed a full and immediate refund from your branch of the amount paid.

You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy of your letter to us.