AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

I (we), hereby authorize EAST FORK SPECIAL UTILITY DISTRICT, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account/Savings Account (select one) indicated below at the depository financial institution named below, hereafter called BANK, and if necessary, initiate adjustments for any transactions debited in error. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Bank Name *

Bank Routing Number *

Bank Checking Account Number *

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner to afford COMPANY and BANK a reasonable opportunity to act on it.

Name on Account *

First

Last

EFSUD Account Number *

Service Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Phone *

Contact Email *

Signature *

Type Your Name Above. This Is Your Signature Affirming the Above Changes.

Voided Check *

Click or drag a file to this area to upload.

Copy of a voided check is required.

NOTE: WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Let's Make Sure Your Not a Bot *

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Bank Draft Form

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)