Section 3 – Direct Debit User Details
Section 2 – Financial Institution Details
Direct Debit Cancellation Request
Note: any Cancellation Request issued on behalf of a new customer under an account switching arrangement must
be signed by the customer in accordance with the relevant account authority.
Section 1 – Customer Authority
Has the customer given a signed cancellation instruction?
if ‘yes’ is the signed cancellation instruction attached or included?
Ledger Institution’s Reference Number
Name of Sponsor Institution Name of Sponsor Institution’s Contact*To
Old Ledger FI name and ACN/ABN/ARBN Name of Old Ledger FI’s contact*CC
*Refer to Appendix B7 of the BECS Procedures for details of Contact and fax number/e-mail address
Ledger FI name and ACN/ABN/ARBN
Commonwealth Bank of Australia ABN 48 123 123 124
Name of Branch or Central contact point
Contact ofﬁcer (full name)
Contact ofﬁcer signature Date
This form is conﬁdential and intended only for the use of the addressee. If you have received this communication in error, please notify the ﬁnancial institution from
which you have received it to arrange disposal. Unauthorised use of the information in this message may result in legal proceedings against the user.
Section 3 – Customer Details
We advise that our Customer(s), whose details are shown below, has/have given instructions that they wish to cancel a Direct
Debit request addressed by them to the Debit User whose name and User ID Number are also shown below.
BSB Account number
Details of account debited:
Name of Debit User
Debit User ID number
Name of Remitter Lodgement reference
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