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2. I (we) hereby authorize the City of Pilot Point to initiate debit entries to my account indicated below.
4. I authorize the City of Pilot Point Water Utility Department to:

   1. Add my utility account to initiate automatic bank draft payments
   2. Remove my utility account from automatic bank draft payments status
   3. Change bank account information for existing automatic bank draft payments
6. I agree to the following:
8. 1. I will provide the City of Pilot Point with a voided check or deposit slip with a copy of this form.
10. 2. I will be responsible for all fees resulting from uncollected payments due to non-sufficient funds, closed bank account, incorrect account number, etc.
12. 3. I attest I am an authorized owner of the account listed below.
14. 4. This authority is to remain in full force until I submit in writing that I wish to terminate.
16. Customer First Name
    As it appears on billing statement.
17. Customer Last Name
    As it appears on billing statement
19. Utility Account Number
20. Physical Service Address
22. Financial Institution/Bank Name
23. Listed Names on Financial/Bank Account
25. Type of Financial/Bank Account

    1. Checking Account
    2. Savings Account
26. Financial/Bank Account Number
27. Financial/Bank Routing Number
29. Customer Signature
30. Today's Date
    Today's Date
32. Phone Number
33. Please attach a copy of a voided check, or ACH form from your Financial Institution/Bank Name.
Leave This Blank:


34. Print Only

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