BANK DRAFT AUTHORIZATION FORM

Bank Draft Authorization Form
Mustang Special Utility District is hereby authorized to draft my bank account on the due date of each month for my monthly water utility bill. I authorize my financial institution indicated below to debit such amounts from my bank account. I understand that my account will be paid by draft until such time as I provide written notification to Mustang Special Utility District to cancel this authorization.
Change Existing Bank Information
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name on Account*

First NameLast Name
Customer Number*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Name of Financial Institution*
Address of Financial Institution*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Type*

CheckingSavings
Account Number*
Bank Routing Number (Nine Digits)*
Please attach a voided check via the File Upload below. Please note that you will continue to receive a monthly statement. The statement will show your current bill with “AUTO PAY” printed under the amount due. If the voided check is not submitted then customer is responsible for any fees charged by the bank and will be removed from bank draft.
File Upload*

Cancelof
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Bank Draft Authorization Form