Bank Draft Form (online)

Complete the online form below or print and complete the .pdf form here and mail to PO Box address listed below.

LIMESTONE COUNTY WATER & SEWER AUTHORITY
P O BOX 110
520 S JEFFERSON ST
ATHENS AL 35612
256-233-6444

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

 I (we) do hereby authorize the above named company, hereinafter referred to as “the company,” to initiate debit entries to my (our) bank account indicated below, hereinafter called “Depository,” and debit the same to such account.

* required fields
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Depository Bank Name*:

City*:

State*:

Zip*:

Routing No*:

Account No*:
(These numbers must be taken from a check – NOT A DEPOSIT SLIP)

Customer #:

Scan and upload copy of check:

This authority is to remain in effect until the company has received WRITTEN
NOTIFICATION from me (or either of us) of its termination in such time and in such a manner
as to afford the company and bank of depository a reasonable opportunity to act upon it.

I understand I will receive my regular monthly bill and the amount shown on the bill will be
debited on the due date each month. If my due date is on a weekend or holiday, my account will
be debited the following business day. I understand if my debit is returned by the bank for
insufficient funds, it is my responsibility to contact the company and make arrangements to
ensure payment. If the debit is returned account closed, I understand my service will be subject
to immediate disconnection.

I accept these terms:

Today's Date: