Check Sample
____________________ ____
ARIZONA WATER COMPANY • SUREPAY APPLICATION AND AUTHORIZATION
I WANT TO SIGN UP FOR SUREPAY FROM MY:
Checking account Savings account
NAME ON WATER ACCOUNT (as it appears on your water bill)
SERVICE ADDRESS
ACCOUNT NUMBER DAYTIME PHONE NUMBER
SUBMIT COMPLETED FORM TO:
Arizona Water Company
PO Box 29098
Phoenix, AZ 85038-9098
or Fax to: 602-240-6874
INCLUDE:
1. Voided check if Checking selected or
Savings deposit slip if Savings selected.
2. Completed and signed application.
MAILING ADDRESS (if different from service address)
I hereby authorize Arizona Water Company ("Company") and the
indicated financial institution to charge my bank account for payment
of my monthly water bill. I understand that both the financial institution
and Company reserve the right to terminate this payment plan and/or
my participation in the plan at any time, and/or impose applicable fees
for rejected payments. I may discontinue my participation in the plan at
any time by notifying the Company.
FINANCIAL INSTITUTION (name and address)
NAME ON BANK ACCOUNT
BANK ROUTING TRANSIT NUMBER BANK ACCOUNT NUMBER SIGNATURE DATE
INSTRUCTIONS FOR COMPLETING SUREPAY APPLICATION AND AUTHORIZATION
• Complete the above application on the screen using Adobe Reader form entry, or print it and complete it by hand.
• Print the application. [If you do not have a printer, call your local Arizona Water Company office to have an application
mailed to you.]
• Sign and date the completed application.
• Attach an original voided check or savings account deposit slip for the account from which funds will be deducted for
SurePay to the completed application.
• Mail the signed application and attachment to:
Arizona Water Company
P. O. Box 29098
Phoenix, AZ 85038-9098 or Fax to: 602-240-6874
NAME ON WATER ACCOUNT: The name that appears
on your monthly water bill.
SERVICE ADDRESS: The address at which water
service is provided.
ACCOUNT NUMBER: Arizona Water Company's
account number for water service to the service address.
DAYTIME PHONE NUMBER: A telephone number at
which you may be reached during the day.
MAILING ADDRESS: The address to which water bills
are mailed.
FINANCIAL INSTITUTION: Name and address of
financial institution at which your checking/savings
account is located.
BANK ROUTING TRANSIT NUMBER: The 9-digit
number on the bottom left corner of your check, usually
between
) symbols.
) !"#$%&') !"#$%&'+
) !"#$%&') !"#$%&'+
BANK ACCOUNT NUMBER: The account number for
your checking/savings account, usually comes before the
+ symbol.
NAME ON BANK ACCOUNT: The name shown on
your bank account.
SIGNATURE: Signature of person authorized to make
withdrawals from your bank account.
Routin
Transit Number
Check #
Account Number
