104 North Second
Customer
Agreement Water/Sewer
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Name_________________________________________________ |
Initial Sign-Up |
______ |
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Change |
______ |
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Delete |
______ |
I hereby authorize the
Village of Dunlap's Bank to withdraw funds for payment of water and sewer
services from the financial institution and account number listed below.
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Financial
Institution/Bank_________________________________________________________________
Address______________________________________________________________________________
City_____________________State_______________ Zip____________Phone
(____)________________
Checking Account
Number:_______________________________________________________________ |
***** Transit/ABA Number ___ ___ ___ ___ ___ ___ ___ ___ ___ *****
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Name
1234 Address
______________20____ Pay to Order of
________________________________________________ $___________ _____________________________________________________________________Dollars
BANK NAME Memo____________________________
_____________________________________
.:
123456789 .: 123 ::456: 1234 |
Transit/ABA
No. ↑ ↑ Account Number
I (we) acknowledge that the origination of ACH
transactions to my (our) account must comply with the provision of
This authority is to remain in full force and effect until
the Village of Dunlap has received written notification from me as to its
termination in such time and in such manner as to afford the Village of Dunlap
a reasonable opportunity to act on it, or until the Village of Dunlap has sent
me 30 days' written notice of their termination of this agreement.
Signed_____________________________________________
Date_____________________________________