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Please Print this out and bring into Water Department
Along with a Blank Check
Or Mail to
Marion Water Department
1102 Tower Square Rd
Marion, Illinois
62959
------------------------------------------------------------------------------------------------------------------------------------------------------------------------ AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS COMPANY NAME: Marion Water Department I (we) hereby authorize _______________________________________________, hereinafter called COMPANY, to initiate debit entries to my (our) checking account indicated below and the depository name below, hereinafter called DEPOSITORY, to debit the same to such account. DEPOSITORY
NAME ______________________________________ BRANCH__________________________________________________ CITY_______________________________________ STATE _____________________________ ZIP _________________ BANK ROUTING# ______________________________________________ BANK ACCT# ______________________________________________ This authority is to remain in full force and effect until COMPANY and DEPOSITORY has received written notification from me (or either of us) of its termination is such time and in such manner as to afford COMPANY and DEPOSITORY as resonable opportunity to act on it. NAMES(S) _________________________________________
(PLEASE PRINT)
WATER ACCOUNT# _______________________________________
DATE______________________ SIGNED X_____________________________________________ SIGNED X___________________________________________________________________ We must have a Blank Check Attached Amount of water bill will be drafter from your checking account approximately 2 days before due date.
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