Date of Issue: July 201
9 | Version: 2
Instructions to your bank or Building Society to pay by Direct Debit.
Please complete this form in full using a ball point pen
and send it to:
Masthaven Bank Limited,
90 Long Acre,
London
WC2E 9RA
The Direct Debit Guarantee
• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct debits.
• If there are any changes to the amount, date or frequency of your Direct Debit, Masthaven Bank Limited will notify you 10 working
days in advance of your account being debited or otherwise agreed. If you request Masthaven Bank Limited to collect a payment,
confirmation of the amount and date will be given to you at the time of the request.
• If an error is made in the payment of your Direct Debit, by Masthaven Bank Limited or your bank or Building Society, you are
entitled to a full and immediate refund of the amount paid from your bank or Building Society.
• If you receive a refund you are not entitled to, you must pay it back when Masthaven Bank Limited asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or Building Society. Written confirmation may be required.
Please also notify us.
Name(s) of account holder(s):
Name and full postal address of your bank or Building Society
To the Manager Bank/Building Society
Address
Post code
Signature(s)
Date
Service User Number
4 4 6 2 0 6
Reference
Instructions to your Bank or Building Society
Please pay Masthaven Bank Limited Direct Debits from the
account details in this instruction, subject to the safeguards
assured by the Direct Debit Guarantee. I understand that this
instruction may remain with Masthaven Bank Limited and,
if so, details will be passed electronically to my bank or
Building Society.
Banks and Building Societies may not accept Direct Debit instructions for some types of account
This Guarantee should be detached and retained by the payer
✁
Bank/Building Society account number
Branch sort code
