Fillable AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS TO BE WITHDRAWN (Town of Chapel Hill)

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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS TO BE WITHDRAWN (Town of Chapel Hill)

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The AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS TO BE WITHDRAWN (Town of Chapel Hill) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Town of Chapel Hill

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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
TO BE WITHDRAWN FROM THE 10
TH
OF EACH MONTH
CUSTOMER NAME: _______________________________________________
SERVICE ADDRESS: _______________________________________________
ACCOUNT NUMBER: ______________________________________________
I (we) hereby authorize TOWN OF CHAPEL HILL, to initiate credit entries to my (our) account indicated
below and the financial institution named below, hereinafter called the FINANCIAL INSTITUTION, to credit
the same to such account I (we) acknowledge that the origination of ACH transactions to my (our) account must
comply with the provisions of U.S. law.
(FINANCIAL INSTITUTION NAME) (BRANCH)
(ADDRESS) (CITY/STATE) (ZIP)
(ROUTING NUMBER--9 DIGITS) (ACCOUNT NUMBER)
TYPE OF ACOUNT: ___________CHECKING __________SAVINGS
This authority is to remain in full force and effect until TOWN OF CHAPEL HILL has received written
notification from me (or either of us) of its termination in such time and manner as to afford TOWN OF
CHAPEL HILL a reasonable opportunity to act on it.
(PRINT NAME) (PHONE NUMBER)
(SIGNATURE) (DATE)
Please email completed form to chtownhall@united.net or mail to:
Town of Chapel Hill, P.O. Box 157, Chapel Hill, TN 37034.
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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS TO BE WITHDRAWN (Town of Chapel Hill)

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Completed 24 January 2021

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