Recurring Credit Card Payment

SW White County Water 2313 HWY 267 South, Searcy, AR 72143

Recurring Credit Card Payments Sign-Up Form

Name on Water Account*

Customer Number

Physical Address (of Meter)*

E Mail Address*

example@example.com

Phone No*

Credit Card Number Set 1*

Credit Card Number Set 2*

Credit Card Number Set 3*

Credit Card Number Set 4*

Expiration Date*

Security Code/CVV*

Name on Card*

Billing Address

City

State

Zip*

This payment will run on the 15th of each month. If that date falls on a non business day, the payment will run the business day BEFORE the 15th.

I certify that the information above is correct, that I am an authorized signer or designate of the account provided for credit card transactions, and that I am authorized to provide this information.

I authorize SW White County Water to deduct my utility payments from this account via Recurring Credit Card Payment transactions. I understand sending a written notification to SW White County Water will revoke this authorization, and must be made 3 days prior to the payment date.

SW White County Water reserves the right to cancel Recurring Credit Card Payments due to insufficient funds without notice.

Print Authorized Name

Authorized Signature*

Clear

Date*

CREDIT CARD INFORMATION