The City of Four Seasons
CUSTOMER SERVICE DIVISION
FFICERS
JOHN F. CONNET
City Manager
S
AMUEL H.
FRITSCHNER
City Attorney
T
AMMIE K. DRAKE
City Clerk
(828) 697-3052
customerservice@hvlnc.gov
CITY COUNCIL:
BARBARA G. VOLK
Mayor
STEVE CARAKER
Mayor Pro Tem
RON STEPHENS
JERRY A. SMITH,
JR. JEFF MILLER
AUTHORIZATION AGREEMENT
AUTOMATIC DRAFT
I (we) hereby authorize The City of Hendersonville Water & Sewer Department, Hereinafter called CITY, to
charge my (our) bank account indicated below the amount due on my account on the bill due date each
month.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the City in writing of any
changes in my account information or termination of this authorization at least 15 days prior to the next billing due date. If the
account due dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I
understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the bill due
date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the City may at is discretion
attempt to process the charge again. I acknowledge that the origination of ACH transactions to my account must comply with the
provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms
indicated in this authorization form.
Name on Water Account
_________________________________
Water Account Number
Signature And Date
_______________________________
Phone Number
COPY OF VOIDED CHECK MUST BE ATTACHED TO THIS FORM!
Complete the form and mail it to the Water/Sewer Department at our City Hall address (provided below) or you
can just drop it off at the Hendersonville Water & Sewer Department located on the lower level of City Hall
anytime between 8 a.m.-5 p.m. Monday
-Friday. If you have any questions, please call us at (828)697-3052.
If you would like to receive your Billing Statements electronically please indicate so below. Opting in to this
service means you will no longer receiving your monthly bill via US Postal Service.
I would like to enroll in the e-billing system
Please direct my bills to the e-mail address
provided
Yes _________ No_________
email address_________________________________
145 Fifth Ave. E.
Hendersonville, NC 28792-4328
customerservice@hvlnc.gov
Phone: 828.697.3052
Find this form online at:
www.hvlnc.gov
Account Type: Checking Savings
Name on Acct _______________________________
Bank Name _______________________________
Bank Routing # _______________________________
Account Number _______________________________
Bank City/State _______________________________
