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I (we) hereby authorize the City of Pilot Point to initiate debit entries to my account indicated below.
1. I will provide the City of Pilot Point with a voided check or deposit slip with a copy of this form.
2. I will be responsible for all fees resulting from uncollected payments due to non-sufficient funds, closed bank account, incorrect account number, etc.
3. I attest I am an authorized owner of the account listed below.
4. This authority is to remain in full force until I submit in writing that I wish to terminate.
As it appears on billing statement.
As it appears on billing statement
Please attach a copy of a voided check, or ACH form from your Financial Institution/Bank Name.
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