(Date)

(Name of requestor)
(Address)

To: (Name of the bank)

I, (name of the requestor), would like to cancel my
arrangement regarding the auto-debit from my (Name of
Bank) Account, with account number 1234567890, to my
(

name

of

insurance

company)

with

policy

0987654321 to take effect immediately.

Thank you for your kind consideration.

number