I [ OF ] [Insert name and address of borrower.] HEREBY CONSENT TO [ ] [Insert name of high cost credit provider.] OR AGENT COLLECTING REPAYMENTS BETWEEN THE HOURS OF 8.00 A.M. AND 10.00 A.M.
Signed:__________________________
Date:__________________________
I UNDERSTAND THAT I MAY CANCEL THIS CONSENT AT ANY TIME BY NOTIFYING THE LENDER EITHER BY USING THE CANCELLATION FORM BELOW OR BY WRITING TO THE LENDER OR HIS AGENT
Cancellation of Consent to Collect Repayments Between the Hours of 8.00 a.m. and 10.00 a.m.
TO [ ] [Insert name of moneylender.]
I [ ] [Insert name and address of borrower.] HEREBY WITHDRAW THE CONSENT I HAVE GIVEN FOR REPAYMENTS TO BE COLLECTED BETWEEN THE HOURS OF 8.00 A.M. AND 10.00 A.M.
Signed:__________________________
Date:__________________________