RVSD - ACH

Name of Financial Institution *

Customer Name (name(s) must match utility billing accounts and bank account) *

Service Address *

City *

State *

Zip Code *

Utility Account Number (found on your Bill XXX-XXXX) *

Phone *

Email Address *

Bank Routing Number (If Your Routing Number starts with a 0 please include the 0) *

Checking Account Number *

Confirm Checking Account Number *

**PLEASE NOTE the automatic withdrawal enrollment will not take effect until your next billing cycle. If you currently have a balance on your account please choose an alternate payment method until your request is processed**

By clicking the box I authorize RAPID VALLEY SANITARY DISTRICT-WATER SERVICE and the financial institution named below to initiate entries to my checking/savings account. this authority will remain in effect until I notify you in writing to cancel it in such time to afford the "District" a reasonable opportunity to act on it.

Signature Statement:

Providing the applicant(s) names below consitutes signature. Additionally, the applicant(s) certify that the information provided on this form is ture and accurate.

Name *

Name

Authorization For Automatic Payment Withdrawl