Automatic Payment Authorization - Borrego Water District

Automatic Payment Authorization Form

Borrego Water District Account Number *

Customer Name *

First

Last

Automatic Debits (Auto Pay) I hereby authorize, Borrego Water District, herinafter called BWD, to initiate debit entries and adjustments for any debit entries in error to my: (Please check one) *

Checking Account
Savings Account

Effective Date *

At the depository institution named below, hereinafter called DEPOSITORY, and to debit or credit the same to such account. *

Bank Location *

City, State Only

Routing Number *

Account Number *

Copy Of Voided Check (Optional)

In order to ensure accuracy please attach a copy of a voided check.

By Pressing Submit Customer Agrees and understands that Borrego Water District will automatically debit authorized account until advised otherwise in writing in such time and in such manner as to afford BWD and DEPOSITORY a reasonable opportunity to act on it. . *

*I understand and agree

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. DEBITS WILL OCCUR AROUND THE 20TH OF EACH MONTH. *Borrego Water District may need to very information and will refer to customer information on file, please ensure your contact information is up to date, auto pay request may be rejected if Borrego Water District is unable to verify customer information.