AUTHORIZATION TO START ACH PAYMENTS
Customer Account Number
Name as it appears on bank account
Checking account number:
Customer contact phone number:
I agree to the following Terms of Agreement:
Payment Notice, Payment Date and Billing Questions
You will continue to receive a monthly statement. If you have any questions about your statement, please contact our office at least 5 business days prior to your due date. On your due date the payment will be deducted from your account. If your due date falls on a weekend or holiday, your account will be charged on the next business day.
Availability of Funds
Accountholder is responsible for ensuring funds are available on the due date. If the transaction is returned from the bank for any reason, a past due notice will then be mailed to you and the payment must be made at our office within 10 days. You will be responsible for all fees charged should your payment be returned for any non-payment reason. (These fees may include late charges, non-payment fees and collections fees.) Your automatic bank payment service may be cancelled if two payments are returned in a 12-month period for non-payment. We also reserve the right to cancel your automatic bank payment service at any time.
Record of Payment
The amount and date of your automatic payment will be shown on your bank statement. This is your proof of payment. If there is a question about a payment or if the amount differs from your bill for any reason, you must notify Jackson County Water within 30 days of the date on which the error occurred.
This authorization will remain in effect until we receive a written notice from you at least 5 business days prior to your due date or until your water service with us is terminated. You may send us a letter requesting the cancellation of Automatic Bank Payment Service (ACH) or stop by our office and sign a cancellation form. At the end of your service, final bills will not be withdrawn via ACH. Please refer to your bill for other final payment options.
Please advise us of any request to stop payment. Charges and/or fees may be applied to any stop payments.
I authorize Jackson County Water Utility, Inc. to collect my monthly utility bill from the bank account listed above.
By typing your name below you agree to the terms of this form and confirm all the information submitted to be true.
Signature (Type your name)
Date (Type today's date ex.. 01/01/2020)