Customer Name Service Address Street Service Address City Service Address ZIP code Mailing Address same as Service Address Yes No Mailing Address Street Mailing Address City Mailing Address ZIP code Billing Account Number EIN number (business owners) Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Phone Number Email Address Is this form being completed by a landlord? Yes No I authorize Highland Sewer & Water Authority to have reoccurring autopay on the account between tenants. please initial here for authorization Bank Information Account Type Checking Savings Depository/Financial Institution Name Branch Street Address Branch City Branch State Branch ZIP code Routing Number Checking/Savings Account Number Attachment(s) Files must be less than 100 MB.Allowed file types: gif jpg jpeg png pdf doc docx. This authorization will remain in full force and effect until Highland Sewer & Water Authority has recevied written notification from me. In order to give Highland Sewer & Water Authority and DEPOSITORY a reasonable opportunity to act, notification must be received no later than 15 days before the next effective transaction date. By clicking submit you agee to the terms listed above. Leave this field blank