UNITED STATES BANKRUPTCY COURT
SOUTHERN DISTRICT OF TEXAS
******* DIVISION

In Re:								Chapter 13 Case No.
(Name of Debtors)						(00-00000-G0-13)

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS (ACH DEBITS)

The undersigned hereby authorizes________________________, Chapter 13 Trustee in the above captioned cause (hereinafter “the Trustee”), to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries made in error to my checking or savings account(s) indicated below at the depository named below (hereinafter called DEPOSITORY), to debit the same to such account, beginning no sooner than the ___ day of ____________, 20__, in the amount of the monthly payment due pursuant to my Chapter  13 Plan, as it may be amended from time to time.
	
DEBIT ENTRIES WILL BE MADE TO THE ACCOUNT ON THE DATE SELECTED BELOW, OR IF THE DATE IS A HOLIDAY, ON THE NEXT BUSINESS DAY FOLLOWING THE DATE SELECTED.

SELECT FROM THE FOLLOWING OPTIONS IF THE TRUSTEE IS WILLIAM HEITKAMP:
	⁭ Deduct the entire payment on the 7th day of the month.
	⁭ Deduct the entire payment on the 23rd day of the month.
	⁭ Deduct one half of the payment on the 7th and one half on the 23rd day of each month.

SELECT FROM THE FOLLOWING OPTIONS IF THE TRUSTEE IS DAVID PEAKE:
    ⁭ Deduct the entire payment on the 5th day of the month.
	⁭ Deduct the entire payment on the 20TH day of the month.
	⁭ Deduct one half of the payment on the 5th and one half on the 20TH day of each month

The name and address of my bank is as follows: 	________________________________
						________________________________
						________________________________

The Transit/ABA number for the bank is:______________________	My account number  is: _____________________
(The Transit/ABA number is a 9 digit number located on the bottom left of your check. You must attach a voided check or deposit slip to this form when you submit the form to the Trustee.)

This authority is to remain in full force and in effect until the Trustee has received written notification from me of its termination in such time and in such manner as to afford the Trustee and DEPOSITORY a reasonable opportunity to act on it, or until the Chapter 13 case is either completed, dismissed, or converted to another chapter. The Trustee is authorized to initiate a debit for the amount of the monthly Chapter 13 Plan payment in the above captioned cause in the amount specified in the Plan or Amended Plan for each month following the date set forth above, or the date of the receipt of this authorization by the Trustee, whichever is later. Completion and submission of this form to the Trustee does not excuse the Debtor in the above captioned Chapter 13 case from the duty to make payments pursuant to the terms of the plan.

NAME : _______________________________	SOCIAL SECURITY NUMBER: ________________________
( Print or type the account holder’s name.)	(Print or type the Social Security or Tax ID number of the account holder.)
	Signed _____________________________	Date _________________________________

YOU MUST MAIL THIS FORM ALONG WITH AN ATTACHED VOIDED CHECK OR DEPOSIT SLIP (OR A COPY THEREOF), TO YOUR CASE TRUSTEE AT ONE OF THE FOLLOWING ADDRESSES:		

William E. Heitkamp, Trustee			David G. Peake
9821 Katy Freeway, Suite 590			9660 Hillcroft, Suite 430
Houston, TX 77024				Houston, TX 77096

DO NOT FILE THIS FORM WITH THE COURT

Processed By: _____________ Date: _________________