BANK DRAFT FORM

BANK DRAFT FORM
TOWN OF SWEPSONVILLE

2747 DARREL NEWTON DR GRAHAM, NC 27253

PHONE (336) 578-5644

FAX (336) 578-5196
ACCOUNT NUMBER*
CUSTOMER NAME*
SERVICE ADDRESS*
BANK INFO

All info is encrypted and secure
BANK NAME*
BANK ACCOUNT NUMBER*
BANK ROUTING NUMBER*
BACNK ACCOUNT TYPE*

CHECKINGSAVINGS
NOTE: ALL PAYMENTS WILL BE DRAFTED ON THE 10TH OF EACH MONTH.
CONTACT INFO

(In case we have questions)
MOBILE PHONE NUMBER*
EMAIL ADDRESS*
example@example.com
SIGNATURE*
YOUR SIGNATURE AUTHORIZES A CREDIT REPORT TO BE ACCESSED
DATE*

MonthDayYear
Date
*Pursuant to 42 US.C. 405(c2Ci), Personal information collected by the Town of Swepsonville will only be used to ensure proper identification in the pursuit of delinquent charges. In no case will the information provided be shared, sold, or otherwise made available for public inspection.
Should be Empty:

BANK INFO