Terminate ACH Payments Form

Name

Service Address

Account Number

Bank Name

Name as it Appears on Bank Account

Checking Account Number:

Routing Number:

Customer Contact Phone Number:

[acceptance* acceptance-409]

I authorize Jackson County Water Utility, Inc. to terminate collection for my monthly utility bill from the bank account listed above. ACH payment must be terminated five (5) working days before the due date.

Signature (Type your name)

Date (Type today's date ex.. 01/01/2020)

Security Code