AUTHORIZATION
FOR PAYMENT
OF MONTHLY
UTILITY BILL BY ACH/DEBIT
I hereby authorize the
Grayson Utilities Commission, hereinafter called COMMISSION, to initiate debit
entries to my account indicated below and the financial institution named
below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such
account for the amount due on the following utility bill(s) on the 10th of
each month.
UTILITY BILL(S) INFORMATION
NAME ACCOUNT
NUMBER
________________________________ _________________
________________________________ _________________
If FINANCIAL INSTITUTION
does not authorize transaction, notice will be mailed to member and late
charges applied.
FINANCIAL INSTITUTION INFORMATION:
(Financial
Institution Name) (Branch)
(Address)
(City/State)
(Zip)
__________________ __________________ Type of Acct: __Checking __Savings
(Routing
Number)
(Account Number)
(Customer Mailing Address)
(City/State)
(Zip)
(Customer Telephone Number)
This authority is to remain
in full force and effect until COMMISSION has received written notification
from me (or either of us) of its termination in such time and manner as to
afford COMMISSION and FINANCIAL INSTITUTION a reasonable opportunity to act on
it.
(Print Individual Name)
(Signature/Date)
PLEASE
ATTACH COPY OF VOIDED CHECK TO THIS FORM!