Revision Date 03/05/2015
Complete form, attach a voided check and return to:
BCPU
P O BOX 469
Bolivia NC 28422
BRUNSWICK COUNTY PUBLIC UTILITIES BANK DRAFT AUTHORIZATION
AUTHORIZATION AGREEMENT ACH (BANK DRAFT) PREAUTHORIZED PAYMENT (DEBITS)
I hereby authorize Brunswick County Public Utilities, hereinafter called COUNTY, to initiate credit entries
or such adjusting entries, either debit or credit, which are necessary for corrections, to my
Checking_____________Savings_____________ account indicated below and the financial institution
named below to credit (or debit) the same to such account. Bank Draft is only processed on the due date
each month. A voided check will be required for processing purposes.
FINANCIAL INSTITUTION NAME CITY STATE
TRANSIT/ROUTING NUMBER ACCOUNT NUMBER
This authorization is to remain in full force and effect until COUNTY has received written notification
from me of its termination in such time and in such manner as to afford COUNTY a reasonable opportunity
to act on it. In an effort to prevent Identity Theft, please include a copy of your driver’s license.
NAME TELEPHONE NUMBER
E-MAIL
DRIVERS LICENSE NUMBER (PLEASE SEND COPY OF YOUR LICENSE)
SERVICE ADDRESS ACCOUNT# & CUSTOMER #
SIGNATURE
