AUTO PAY AUTHORIZATION FORM
BREVARD COUNTY UTILITY SERVICES
Account Number Customer Name (as it appears on your bill)
vice Address Name of Financial Institution
Daytime Telephone (with area code) Type of Account (Select One)
When setting up auto pay be prepared with your account number, routing number, and
identification when going to your local customer service office.
I authorize Brevard County Ut
ility Services to automatically initiate charges (debit
entries) to my bank account as indicated herein, and for my bank to accept and post
such charges for the payment of all bills rendered to me by Brevard County Utilities.
Brevard County Utility Services will continue to send me a statement each month. Your
account will be charged 1-2 days before statement is due. Brevard County Utility
Services will impose a service charge in the event a charge is not paid by my
I understand that I may discontinue this payment service by notifying my local customer
service office in writing, before the next billing cycle is completed.
Please sign and date this form if you agree to accept these terms as stated above.
Account Holder Signature Date
Secondary Account Holder Signature Date
Customer Service Offices
Barefoot Bay Water and Sewer
931 Barefoot Blvd., Suite 2
Barefoot Bay, FL 32976-76-1
North Brevard Water and Sewer
2262 High Dr.
Mims, FL 32754-2016