Metropolitan Domestic Water Improvement District
P.O. Box 36870 Tucson, Arizona 85740 (520) 575-8100 (520) 575-8454 FAX
NAME ON METRO WATER ACCOUNT: _________________________________________________________
METRO WATER ACCOUNT #: __________________________________________________________________
SERVICE ADDRESS: __________________________________________________________________________
CITY: _______________________ STATE: ______________ ZIPCODE: ______________________________
HOME PHONE: ( ) _________________________ DAYTIME PHONE: ( ) ________________________
NAME OF FINANCIAL INSTITUION: ____________________________________________________________
BANK PHONE #: ( ) _______________________________________________________________________
ROUTING #: _____________________________ ACCOUNT #: ________________________________________
I hereby authorize Metro Water District and the financial institution designated above to charge the
account I have specified for payment of my water utility bill. I understand that a fee will be charged to my
account each time a check is returned for any reason. In addition, I understand both the financial
institution and Metro Water reserve the right to terminate this payment plan and/or my participation
therein. Should I choose to withdraw from the plan, I will notify the Metro Water within a timely manner.
Signature: ___________________________________________ Date: ____________________
***Note: You will be notified on your statement when direct pay goes into effect. Please continue paying towards
your water bill until you see on your billing statement.***
To Complete Application, Please
Attach A VOIDED Check