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Bank Draft Authorization Form

DOUGLASVILLE-DOUGLAS COUNTY WATER AND SEWER AUTHORITY

BANK DRAFT AUTHORIZATION FORM

Customer Name

First

Middle

Last

Customer Account Number

Phone Number

Service Address

Address Line 1

City

State

Zip Code

BANK DETAILS

Type

Name of the Bank

Bank Location

Bank Account Number

Bank Routing Number

Authorization for Bank Draft Enrollment:

As a convenience to me, I hereby authorize the Douglasville – Douglas County Water and Sewer Authority (the “Authority”) to initiate debit entries to my account at the financial institution identified on this form (the “Bank”) Payable to the Douglasville – Douglas County Water and Sewer Authority for payment of any monthly charges billed to the account listed on this form. As used in this authorization, “I,” “me,” and “my” mean the customer of record signing this form for the Authority account identified above. By signing below, I agree that any such debit presented by the Authority that is dishonored by the Bank for any reason will bear the same consequences as though it were a check made, drawn, and presented by me in payment of my monthly charges for service. This authorization will remain in force until the Authority and the Bank have received written notification from me at least thirty (30) days before its termination, including my right to stop payment of a debit entry by notification to the bank prior to the date the charge is made.

Further, I understand and acknowledge the following.

My account will not be activated for bank draft until my account shows a zero balance.
My payment should be submitted by mail, phone, in-person, or through the Authority website until the notation “Bank Draft Do Not Pay” appears on my billing statement.
The amount drafted will vary from month to month based on current billing and actual usage. Even if my usage is usually consistent, my bill may increase unexpectedly due to a leak or other additional usage.
I have attached a copy of a voided check or bank account specification sheet.
I agree that my written or electronic signature on this form will serve as the authorized signature for each debit transaction under this authorization, and that this authorization may be stored electronically and any electronic copy, including the signatures thereto, will be deemed an original, admissible and enforceable to the same extent as a paper original.

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Please attach a voided check or a bank account specification sheet to verify your banking information.

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BANK DRAFT AUTHORIZATION FORM

Further, I understand and acknowledge the following.