Auto Draft Payment Application

Auto Draft Payment Application
Account Number:*
Account Number can be found on our Utility Bill
Account Holder's Name:*
Account Holders Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Account Holders Phone:*
Account Holders Email:
example@example.com
Financial Institution*
Type of Account*

CheckingSavings
Bank City and State:*
Bank Routing Number:*
Bank 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

Clear
Date

MonthDayYear
Date
Should be Empty: