Authorization for ACH AutoDraft

Customer Name

Service Address Street

Service Address City

Service Address ZIP code

Mailing Address same as Service Address

Yes

Mailing Address Street

Mailing Address City

Mailing Address ZIP code

Billing Account Number

EIN number (business owners)

Date of Birth

Month

Day

Year

Phone Number

Email Address

Is this form being completed by a landlord?

Yes

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

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