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?
Yes No
Date sent
Ledger Institution’s Reference Number
Name of Sponsor Institution Name of Sponsor Institution’s Contact*To
Fax number
Email address
Old Ledger FI name and ACN/ABN/ARBN Name of Old Ledger FI’s contact*CC
Fax number
Email address
*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
Fax number
Email address
Contact officer (full name)
Contact officer signature Date
Confidential Communication
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.
Customer name(s)
BSB Account number
Details of account debited:
Name of Debit User
Debit User ID number
Name of Remitter Lodgement reference
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Section 3 – Direct Debit User Details (continued)
Section 4 – Customer Declaration
In accordance with Clause 7.5 of the BECS Procedures, please PROMPTLY forward a copy of this Cancellation Request to the Debit User, who is to act promptly
under Clause 7.10 of the BECS Procedures in accordance with an instruction to cancel a Direct Debit Request.
Date the Customer’s account was last debited Amount
I/We confirm that I am/we are authorised to operate the account represented by the BSB and Account number
detailed above. I/We authorise Commonwealth Bank to submit this Cancellation Request on my/our behalf.
Customer name(s) 1
Customer name(s) 2
Signature of customer 1
Signature of customer 2
Thank you for completing this form
Customer’s identification number(s) with the Debit User (if known) (Examples: Customer’s Billing number, Contract number or Policy)
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