E-billing & Automatic Recurring Bank Draft Authorization Form
This authorization form is for any and all service locations associated with your account number. If you have multiple account
numbers you must fill out a form for each account number.
Account Number (as shown on your bill):__________________________________________________________________________
Name (as shown on your bill):___________________________________________________________________________________
Service Address(es):__________________________________________________________________________________________
___________________________________________________________________________________________________________
Home Phone: ___________________________________Cell Phone: __________________________________________________
Email Address: ______________________________________________________________________________________________
E-Billing
Yes, I agree to receive my bill by email. I understand I will no longer receive a paper bill and have read the terms and conditions.
Update information Cancel e-bill
Terms and Conditions:
I confirm that I am the account holder and authorize the RCPSA to discontinue mailing my bills. I understand I will receive my bill, including
any adjusted or delinquent bills, by email. It is my responsibility to update my account as necessary and to add the RCPSA to my ‘Safe
Sender list’ and address book. If my e-bill is undeliverable, I will be sent a paper bill and removed from the e-bill service.
ACH Draft
Yes, I agree to have my bill payment automatically withdrawn from my bank account and have read the terms and conditions.
Update information Cancel ACH draft
Name(s) on the Account: ______________________________________________________________________________________
Bank Name: ________________________________________________________________________________________________
Routing Number: ____________________________________ Account Number: _________________________________________
Account Type: Checking Savings --You must include a voided check (starter checks are not accepted) or if you wish funds to be
deducted from your savings account, provide a bank document showing your name, routing number and savings account number.
Terms and Conditions:
I authorize the RCPSA to deduct payment(s) automatically for the account number specified, for charges incurred at the service address(es)
associated with my account. I understand that payments will be deducted on the due date of my bill(s), and that each service address bill
payment will show on my bank statement as a separate draft. I also understand that I will be subject to the current return check fee, and that
penalty charges will be assessed if insufficient funds are available at the time of the electronic fund transfer. I further understand that I have
the right to receive notice of the amount of each payment deduction, and that each bill I receive from the RCPSA will constitute such notice.
Should I wish to cancel my authorization, change or close my bank account, it is my responsibility to contact the RCPSA in writing at least 10
business days prior to my next bill due date. I understand that if corrections to my account are necessary, they will be reflected on my next bi-
monthly bill. I understand that this authorization is non-negotiable and non-transferrable. I also understand and agree that the RCPSA
reserves the right to terminate this draft and/or my participation in it.
I have read and agree to the above authorization agreement.
Signature:___________________________________________ Date:_________________________
Mail or bring completed application to:
Rockbridge County PSA
150 S Main St
Lexington, VA 24450
Or scan and email to rcpsa@rockbridgecountyva.gov
Rockbridge County Public Service Authority is an equal opportunity provider.
Office use only
Service ID: ___________________________________
Entered on: ____________By:___________________
