(Rev: 10/2013)
TOWN OF ELON
104 S Williamson Ave
Elon, NC 27244
Phone: 336-584-0282
AUTHORIZATION FOR AUTOMATIC DEBITS
(DRAFT WATER PAYMENTS)
W/S Services Account #: ____________
Customer’s Name:________________________________________________________
Service Address:_________________________________________________________
I hereby authorize the Town of Elon to initiate debit entries and to initiate, if
necessary, credit entries and adjustments for any debit entries in error to my checking
account indicated below and the financial institution named below, to debit and/or credit
the same to such account.
Financial Institution_____________________________ Branch____________________
City_____________________________ State________ Zip Code___________________
Transit/ABA No.________________________ Checking A/C #____________________
(9 digits)
This authority is to remain in full force and effect until the Town of Elon has
received written notification from me of its termination in such time and in such manner
as to afford the Town of Elon and the financial institution named above a reasonable
opportunity to act on it.
Name:_____________________________________Phone #_(______)(_____________)
Area Code Phone Number
Signature:________________________________ Date Signed____________________
*****PLEASE ATTACH A VOIDED CHECK*****
Please notify us when changing banks or if you wish to cancel your draft.
Return this completed draft authorization to: Town of Elon
P. O. Box 595
Elon NC 27244
