[Form Title]

Ref No.: [Submission Reference]
Date: [Submission Date]

I, [Field 4] [Field 5], residing at [Address Line1 Field 7], [City Field 9], [State Field 10], [Country Field 12], hereby authorize Company XYZ to initiate debit entries to my bank account as specified below for the payment of my loan amount [Field 25]. The purpose of the loan is [Field 26].

By signing this document, you authorize Company XYZ to debit your account for the payment of the agreed loan amount. Please ensure sufficient funds are available. This authorization remains in effect until the loan amount is fully paid or you cancel the authorization with at least 30 days of advance written notice. For any queries, contact us at [Field 14].

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