Auto Debit Authorization Form
I hereby authorize Broward County Water and Wastewater Services (WWS) to automatically withdraw
funds from my bank account (shown below) each month, to pay my utility bill on the due date shown on
the bill. If the payment due date falls on a weekend or holiday, I understand that the withdrawal may be
executed on the next business day. This authorization will remain in effect until WWS receives a written
notice from me regarding changes to the banking information provided or terminating this authorization,
at least 15 days prior to the next billing date. I also acknowledge that I am still responsible for payment of
my bill by the due date after termination of this authorization. I understand that WWS reserves the right
to terminate my participation in this payment option after 2 automated withdrawals are declined by my
bank within a 12-month period and the account can be placed on 'Cash Only' status for one year. I
understand that a returned item fee will be charged by WWS for all withdrawals declined by my bank
due to insufficient funds or account changes, and the fee will be based on the amount of the declined
transaction.
Please complete the information below then sign and date the form:
WWS Account Name WWS Customer # (located top left of your invoice)
Service Address Phone #
City, State, Zip Email Address
I would like to receive an electronic bill instead of a paper bill? Yes No
Account Type:
Checking
Savings (Obtain Account & Routing Number from Bank)
Name on Account
Bank Name
Bank Routing #
Bank Account #
By printing my first and last name in the signature field below I am confirming that the information
provided is current and accurate. This form will be submitted to a secure internal document
management system for processing.
SIGNATURE DATE
BOARD OF COUNTY COMMISSIONERS
WATER AND WASTEWATER SERVICES (WWS)
BUSINESS OPERATIONS DIVISION
2555 WEST COPANS ROAD, BLDG. 1
POMPANO BEACH, FL 33069
(954) 831-3250 ● water@broward.org
Internal Use Only:
Set Up Date:
CSR Initials:
Revised Novem
ber 2019
