SAGINAW CHARTER TOWNSHIP WATER DEPARTMENT

Authorization Agreement for Automatic Bill Payment

I (we) hereby authorize Saginaw Charter Township to initiate debit entries to my (our) Checking or Savings account (circle one) and the depository named below, hereinafter called depository, to debit same to such account.

DEPOSITORY/BANK INFORMATION:
DEPOSITORY NAME:_______________________________________________________________________
CITY & STATE: ____________________________________________________________________________
ABA/ROUTING NO.:_________________________ YOUR ACCOUNT NO.___________________________
(9 digits on bottom of check)

This authority is to remain in full force and effect until Saginaw Charter Township and depository has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Saginaw Charter Township and the depository a reasonable opportunity to act on it.

CUSTOMER INFORMATION

CUSTOMER NAME(S): ___________________________________________________________
SERVICE ADDRESS:______________________________________________________________
WATER ACCOUNT:_______________________________________________________________

SIGNED:________________________________ DATE:______________________