Bank Authorization

Cycle:_____

Clark-Edgar Rural Water District

475 IL Hwy 1, P.O. Box 297, Marshall, IL 62441

1-800-966-5888 or 217-463-5888

 

Authorization Agreement for Automatic Withdraw Payments

I (we) agree to pay the monthly charge of $0.25 per month for the automatic payment option. Furthermore, the authority will remain effective until the Clark-Edgar Rural Water District has received from me (us), the customer, a written notice of termination or at the discretion of the water district. This agreement is subject to the same guidelines and fees as returned checks. Should there be two (2) returned drafts, the agreement is automatically void and payments will need to be made by cash, or money order.

CERWD Account Number: _______________________________________________

Name on Account: ______________________________________________________

Address: ______________________________________________________________

City: __________________________           State: ________          Zip: ____________

I (we) hereby authorize the Clark-Edgar Rural Water District to initiate debit entries to my (our) checking or savings account indicated below.

Bank Name: __________________________________________________________

Address: ______________________________________________________________

City: ___________________________         State: ________          Zip: ____________

Account Number: _______________________________________________________

Transit Routing Number: _________________________________________________

Type of Account: Checking _________       Savings _________

Date: _______________________

Signature(s): ___________________________________________________________

Print Name(s): __________________________________________________________