To The Manager:
(Bank's name and address)

____________________________ Bank

____________________________

____________________________

Please pay the sum of £______ (in words:_______________________________________ )
from my account (enter your account details):

Sort code ______ ______ ______ Account No: ___________________________________

on the _________ day of each month, with effect from: ___________________________

until further notice/with a final payment on*____________ (*please delete as appropriate).

(This cancels and supersedes any previous instructions.)