Automatic Bill Pay Authorization

Automatic Bill Pay Authorization
FORM:

AUTOMATIC BILL PAY AUTHORIZATION (ACH)
NOTE: * indicates a required field
I hereby authorize Atascadero Mutual Water Company ("AMWC") to automatically deduct funds for the payment of my monthly water bill from the bank account identified below.
Customer Information
AMWC Account Number:*
Lot No
Service Address:*
Name:*
Property Owner (Shareholder)
Mailing/Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Business Phone
Do you have a landline?*

YESNO
Home Phone
E-mail*

Customer Bank Account Information
Type of Account:*

CheckingSavings
VOIDED CHECK: Please attach a copy or take a photo of your voided check*

Upload a File

Cancelof

Terms and Conditions
This authorization will remain in effect until cancelled by either party.
- I agree to notify AMWC as soon as possible if my bank account information changes
- I agree that, unless I contest the charges appearing on my monthly water bill within 10 calendar days from the bill date, the funds for the water bill will automatically be deducted from the above bank account on the due date.
- I agree that if sufficient funds are not available in the above bank account to allow the bank to automatically process payment of the outstanding balance on my monthly water bill, I will pay AMWC, with cash or money order, the outstanding balance plus a returned check fee.
Please check:*

I agree to the above Terms and Conditions
Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature, or any resulting agreement between you and AMWC. In addition, you are confirming that you are the shareholder authorized to enter into this Agreement.
I Accept*

By checking this box and typing my name below, I agree to the terms and conditions of the Electronic Signature Agreement, and I am electronically signing my application.
First Name*
Middle Initial
Last Name*
Date*

MonthDayYear
Date
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