Automatic Withdrawal Program (ACH) Form Authorization Agreement for Preauthorized ACH Debits/Credits "*" indicates required fields Customer Name* First Last Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Service Account #* Service Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I (we) hereby authorize CRESTVIEW WATER AND SANITATION DISTRICT hereafter called COMPANY, to initiate debit entries to my (our) Checking or Savings account indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account.DEPOSITORY NAME: INDEPENDENT BANKThis authority is to remain in full force and effect until COMPANY AND DEPOSITORY has received written notification from me (us) of its termination in such time and in such manner as to afford COMPANY AND DEPOSITORY a reasonable opportunity to act on it.Bank Information Source* Manual Entry Scanned Check Routing Number Account Number Scanned CheckMax. file size: 100 MB.COMPLETED FORM WITH AN ATTACHED VOIDED CHECK MUST BE RETURNED TO CRESTVIEW WATER & SANITATION DISTRICT BEFORE THE AUTOMATIC WITHDRAWAL PROGRAM CAN BEGIN.Email Address* Email Only Billing* Yes No PLEASE NOTE: This transition may take up to 30 days before taking effect.Signature #1*Signature #2Date* Month Day Year CAPTCHA