Auto Draft Payment Application

CITY OF MOUNT PLEASANT

Auto Draft Payment Application
Account Number:*
See Example Below to Locate Account Number
Account Holder's Name:*
Account Holders Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Holders Phone:*
Financial Institution*
Type of Account*

CheckingSavings
Bank City and State:*
Routing Number:*
Account Number:*
I hereby authorize Mount Pleasant Utility System to initiate electronic debit entries, from the account listed above, for payment of my utility bills. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until i have cancelled it in writing.
Signature

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Date

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Date
Should be Empty:

CITY OF MOUNT PLEASANT