Authorization Agreement For Direct Payment

*(EFT, ACH, DRAFT)

Check appropriate box:

I (we) hereby authorize Holly Springs Utility Department to initiate debit entries to my (our)

(select one)

Checking

Savings

account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account.*

I (we) hereby request that Holly Springs Utility Department discontinue debit entries to my (our)

(select one)

Checking

Savings

account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY.

Financial Institution Name (Required)

Branch

City (Required)

State (Required)

ZIP (Required)

Nine Digit Routing Number (Required)

Account Number (Required)

This authorization is to remain in full force and effect until Holly Springs Utility Department has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Holly Springs Utility Department and Depository a reasonable opportunity to act on it.

Name on Utility Bill (Required)

Utility Bill Account Number (Required)

Utility Bill Account Number 2 (Optional)

Utility Bill Account Number 3 (Optional)

Authorized Signature (Required)

Date (Required)

Authorized Signature 2 (Optional)

Date (Optional)

NOTE: All written debit authorization must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.

*PLEASE UPLOAD A VOIDED CHECK TO INSURE PROPER DEBITING OF YOUR ACCOUNT

File Upload (File must be less than 10 MB and be one of the following formats; jpg, jpeg, png, tif, tiff, pdf):