DECEMBER 12, 2000 - Toledo Bend



SOUTH TOLEDO BEND WATER DISTRICT

PO BOX 60

MANY, LA 71449-0060

BILLING (318)256-2725 OR –5714 FAX 256-5758

WATER PLANT (318)586-9836

Website:

RECURRING EFT PAYMENT AUTHORIZATION

NAME ON WATER ACCOUNT:

WATER ACCOUNT NUMBER:

HOME TELEPHONE NUMBER:

CELL PHONE NUMBER:

CURRENT MAILING ADDRESS:

CURRENT CITY, STATE & ZIP:

U.S. BANK ACCOUNT INFORMATION:

NAME OF FINANCIAL INSTITUTION:

CITY, STATE & ZIP CODE:

BANK CONTACT TELEPHONE #:

NAME ON BANK ACCOUNT:

BANK ACCOUNT NUMBER:

BANK ROUTING NUMBER (9-DIGIT #):

**SEND A VOIDED CHECK WITH AUTHORIZATION FORM**

CUSTOMER AUTHORIZATION:

I hereby authorize the financial institution named above to pay the monthly water bill. I have the right to stop payment of a charge by timely notification to my financial institution, and South Toledo Bend Water District reserves the right to terminate this EFT payment authorization or my participation therein. I also certify that I am an authorized signer on the above bank account.

CUSTOMER SIGNATURE:

DATE:

INSTRUCTIONS:

Please return this signed form and voided check to any of the following:

Email: cpas3@

Fax: (318)256-5758

Mail: PO Box 60, Many, LA 71449-0060

Please continue to pay your water bill with check until you see note on your bill that EFT payment will be executed for that water bill. You will continue to receive a monthly bill showing the water account balance that will be deducted from your bank account. The payment amount will be shown in the box labeled “DUE NOW” on your water bill. It will normally be deducted by the 20th day of each month.

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