ACH Direct Payment Authorization Form

Date

Month

Day

Year

Is this a new ACH or are you just changing bank information?

New ACH

Changing Bank Information

First name

Last name

Service Address

Financial Institution Name

Account Type

Checking Account

Savings Account

Account Number

Routing Number

Charge my account the amount due on my water bill

The 5th of each month

The 20th of each month

I authorize Clay Rural Water System, Inc to initiate electronic debit entrees to my checking/savings account in the amount of my water bill. This authority will remain in effect until I have cancelled in writing. I can stop payment of any entry by notifying Clay Rural Water System

Signature

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Printed Name