Automatic Withdrawal Program (ACH) Form

Authorization Agreement for Preauthorized ACH Debits/Credits

"*" indicates required fields

Customer Name*

First Last

Mailing Address*

Street Address City State ZIP Code

Phone Number*

Service Account #*

Service Address*

Street Address City 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 BANK

This 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 Check

Max. 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

PLEASE NOTE: This transition may take up to 30 days before taking effect.

Signature #1*

Signature #2

Date*

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