SNAKE RIVER WASTEWATER TREATMENT PLANT
970.668.4270 ph | 970.468.6393 f 4344 Swan Mountain Rd.
www.SummitCountyCO.gov/snakeriver Dillon, CO 80435
AUTHORIZATION FOR ELECTRONIC WITHDRAWAL
DATE:
OWNER:
Snake River Account #
Street Address of Property:
Lot Block Subdivision
PLEASE INCLUDE A VOIDED CHECK (or copy) to ensure the proper account is drafted.
Bank Name:
Date:
I authorize Summit County Treasurer's Office to electronically withdraw funds for my quarterly Snake
River Sewer account balance payment, from the following financial institution:
Payments will be withdrawn on due date. (Due dates are February1, May1, August 1, and November1.)
Forms must be received 14 days prior to due date to be processed for that due date.
For questions, please call (970) 668-4270
Return authorization by mail, fax 970-468-6393 or email Karen.Bailey@SummitCountyCO.gov
Bank Routing Number:
Account Number:
Signature:
