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City of Pilot Point Automatic Bank Draft Payment Authorization Form

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