AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENT TO THE
CITY OF KINGSPORT
I (We) hereby authorize the City of Kingsport, hereafter called the CITY, to initiate debit entries and initiate, if necessary, credit entry adjustments
for any debit entries in error to my (our) checking or savings account indicated below and the depository named below, hereafter called the
DEPOSITORY, to debit and/or credit the same to such account. These debits will be made monthly on the last business day prior to the
penalty date of the current bill.
DEPOSITORY NAME ____________________________________________ BRANCH
CITY _________________________________________________________ STATE ZIP
BK TRANSIT/ABA NO. __________________________________________ ACCOUNT NO.
ACCOUNT TYPE: ( ) CHECKING ( ) SAVINGS
This authority is to remain in full force and effect until CITY or Customer has given written notification of its termination in such time and
in such manner as to afford CITY and DEPOSITORY or Customer a reasonable opportunity to act on it.
CUSTOMER(S) NAME
SOCIAL SECURITY NO. - -
WATER ACCOUNT NO. --
MAILING ADDRESS
ZIP --
DATE: , 20 SIGNATURES
OFFICE USE ONLY
The convenience of payment of your water bill by preauthorized bank draft is now available, therefore eliminating:
The writing of a check every month
Postage expense
Standing in line to make payment
Worrying about paying your water bill on time, even if you're out of town
TO INITIATE PAYMENT OF YOUR WATER BILL BY PREAUTHORIZED BANK DRAFT, SIMPLY COMPLETE THE ABOVE FORM AS PER THE
FOLLOWING INSTRUCTIONS AND RETURN IT TO THE CITY OF KINGSPORT WATER DEPARTMENT ALONG WITH A DEPOSIT SLIP OR A
VOIDED CHECK
Depository Name - Enter the name of the financial institution at which you have an established checking or savings account from
which you wish to preauthorize payment to the City for your monthly water bill.
City, State, Zip - Enter bank address.
BK transit/ABA No. - Enter the American Banking Association (ABA) number, i.e., the account number that identifies your
financial institution to the Federal Reserve System. This number is encoded on your checks.
Account No. - Enter the number assigned by your financial institution identifying your account. This number can generally be
obtained from your bank statement and is encoded on your checks.
Account Type - Check the appropriate block.
Water Account Number - Enter the number assigned by the Water Department to identify your account. This number can be
obtained from your water bill. It is the ten-twelve digit number located in the upper left hand corner of your water bill.
Mailing Address - The address where your bill is currently mailed.
Date – Current date.
Signature Form must be signed by customer.
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signature
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