CHPMD - Authorization Agreement for Direct Deposits (ACH Debits)

Chaparral Pointe Metropolitan District
614 N. Tejon St Colorado Springs, CO 80903 (719) 447-1777
Authorization Agreement for Direct Deposits (ACH Debits)
DISTRICT ID NUMBER: 83-3492239
I (we) hereby authorize Chaparral Pointe Metropolitan District (and/or its duly authorized Manager), hereinafter called the DISTRICT, to initiate Debit entries to my (our) Checking Account indicated below at the depository financial institution named below, hereinafter called the DEPOSITORY, and to Debit the amount of the District’s monthly water billing to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.
DEPOSITORY NAME*
Example: JP Morgan
BRANCH*
Example: Chase is a Branch of JP Morgan
CITY*
City your bank is located at
STATE*
Where your bank is located
ZIP
ROUTING NUMBER*
BANK ACCOUNT*
* The routing number and bank account information can be found on a check for the account as shown on the picture below. If you want to insure that the above information is correctly entered, you may attach a voided check or a cancelled check to the District from a previous payment.
This authorization is to remain in full force and effect until the DISTRICT has received written and signed notification from me (or either of us) of its termination in such time and in such manner as to afford the DISTRICT and the DEPOSITORY a reasonable opportunity to act on it.
NAME(S) on the Account*
District ACCOUNT #*
SERVICE ADDRESS*
CUSTOMER PHONE*
DATE*

MonthDayYear
Date
PRINTED NAME Authorizing Auto-Pay*
SIGNATURE*

Clear
Note: All written Debit authorizations should provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.
Should be Empty:

Chaparral Pointe Metropolitan District

Authorization Agreement for Direct Deposits (ACH Debits)

DISTRICT ID NUMBER: 83-3492239