[Bank/building society address]
[Reference: Cancellation of a direct debit]
Account number: [xx]
Sort code: [xx]
Company name: [name of organisation taking the Direct Debit]
Reference: [insert the Direct Debit reference from your bank statement]
Amount: [if known, or variable]
Date: [eg 1st of the month]
Please cancel the Direct Debit Instruction detailed above effective from [insert date].
I have copied this letter to [insert organisation name] for their information.