Authorization Agreement For
Automated Clearing House Transactions
(ACH Debits)
Customer Information
Zip
Bank Account #
ACH Debit 5/24/2018
Individual/Company Name
Select type and provide appropriate account number
Address
City
State
Above named Customer hereby authorizes Sussex County to initiate Automated Clearing House
electronic funds transfer (EFT) debit entries to Customer's account, as indicated below.
Accounting/ACH Contact Name
Email Address for Statement (Required)
Once enrolled, billing statements will be sent to this address
Phone (Required)
Name on Bank Account
Bank Routing Number*
* Provide the 9 digit bank routing number from a check. The routing number from a deposit slip is invalid.
This authority is to remain in full force and effect until Sussex County has received notification from an
authorized person for this account of its termination in such time and manner as to afford Sussex County
and your Bank a reasonable opportunity to act on it.
Customer Authorization:
Authorized Name/Title Authorized Signature
Date
Date Received:
Billing Use:
Date Entered:
Entered By:
Fax
Checking Savings New Setup Change
Bank Name
Banking Information
General Billing
Sewer Utility
Customer #
Account #
Please return completed form to:
Sussex County Billing Division
PO Box 601
Georgetown, DE 19947
click to sign
signature
click to edit
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