SIGNAL MOUNTAIN WATER COMPANY
ACH DRAFT BANKING AUTHORIZATION
_________________________________ ______________________
(Name-Please Print) Water Account Number
_________________________________ _____________________
Phone Number Address
Email___________________________________
I authorize the Signal Mountain Water Dept. and the financial institution named below to
initiate entries to my checking/savings accounts, and, if necessary, initiate adjustments
for any transactions credited in error. This authority will remain in effect until I notify
you in writing to cancel it in such time as to afford the financial institution a reasonable
opportunity to act on it. I can stop payment of any entry by notifying my financial
institution 30 days before my account is charged. I can have the amount of an erroneous
charge immediately credited to my account up to 10 days following issuance of my
quarterly water billing. After your water bill is applied to your account, payments are
withdrawn from your bank account three business days before the due date on the water
bill.
(Name of financial institution)
(Signature) (Date)
Checking A/C #____________________ (or) Savings A/C #_______________________
Financial Institution Routing #_______________________________________________
PLEASE PROVIDE A VOIDED CHECK TO ENSURE CORRECT BANK INFORMATION
NOTE: In the case of revoked authorization, all written authorization must be revoked
only by notifying the Signal Mountain Water Company in writing no later than 30 days
before the next transaction effective date. A fee of $35.00 will be imposed on any
transaction not honored by your financial institution. Should this problem not be
resolved within 7 days, water service will be terminated and a $25.00 disconnect fee will
be charged.
