ACH BANK DRAFT

First draft date

MonthDayYear
Date
WATER ACCOUNT #
BANK DRAFTS ARE SUBMITTED ON THE 5th OF THE MONTH. (If the 5th is on the weekend or holiday the draft will be submitted the next working day

GRAND PRAIRIE BAYOU TWO P.W.A. AUTOMATIC BANK DRAFT AUTHORIZATION
NAME: (As it appears on your Grand Prairie Bayou Two P.W.A. statement)
Address
City
State
Zip Code
Home/Cell Phone
E Mail Address
example@example.com
PLEASE MARK ONE:
I WANT A PAPER BILL & E MAIL
example@example.com
NO, I DO NOT WANT A PAPER BILL (E MAIL ONLY)
example@example.com
NAME OF YOUR FINANCIAL INSTITUTION
(As it appears on your bank account)
BANK ROUTING NUMBER
Bank Account Number
I authorize the financial institution named above to pay my monthly Grand Prairie Bayou Two P.W.A. water bill and to deduct each payment from my checking/savings account. This authority is to remain in effect until revoked by me in writing. I agree that each payment shall be the same as a check personally signed by me. I have the right to stop payment of a charge by timely notification to my financial institution and Grand Prairie Bayou Two P.W.A. reserves the right to terminate this draft service (or my participation therein
SIGNATURE

Clear
DATE

MonthDayYear
Date
Please include this form with your payment check, or enclose a voided personal check. Mail to: Grand Prairie Bayou Two P.W.A. 11177 AR Hwy 31 N. Austin, AR 72007
Should be Empty:

PLEASE MARK ONE: