ACH BANK DRAFT SIGN UP FORM
Name: __________________________________________________
Account Number:__________________________________________
Email Address:____________________________________________
Phone Number:____________________________________________
Bank Name:______________________________________________
Bank Routing/Transit Number:________________________________
Name on Account:_________________________________________
Account Type (Checking/Savings):_____________________________
Account Number:__________________________________________
I certify that the information above is correct, that I am an authorized signer or designate of the account provided for ACH transactions, and that I am authorized to provide this information.
I authorize Corbett Water District to deduct my utility payments from this bank account via Electronic Fund Transfer. I understand sending a written notification to Corbett Water District will revoke this authorization.
Corbett Water District reserves the right to cancel Electronic Fund Transfers due to insufficient funds without notice.
A voided check must be sent with the application.
Printed Name:____________________________________________
Authorized Signature:_______________________________________
Date:___________________________________________________
