"P:\Forms & Templates\Customer Service\ACH Application 2-15-21 FILL IN FORM.pdf"
ACH
Using ACH, you can pay your Water/Sewer Bills directly from your bank account. Sign up below to have your
Utility Bill deducted directly from your bank account beginning with your next billing cycle.
Please select one: New Account Change Existing Account Information
Debit Authorization Form
I (we) hereby authorize the Waukesha Water Utility (WWU) to withdraw payment for my (our) City of
Waukesha Water/Sewer Bill from my (our) checking/savings account at my (our) financial institution, as
indicated below. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply
with the provisions of U.S. law.
WWU Account Number ___________________________ WWU Customer Number______________________________
Name(s) shown on WWU Bill_________________________________________________________________________
Service Address___________________________________________________________________________________
Billing Address (if different)___________________________________________________________________________
Home Telephone________________________________ Work Telephone_____________________________________
Financial Institution (Bank) Name______________________________________________________________________
Bank Address_____________________________________________________________________________________
Bank Routing (ABA) Number______________________________ Account Number_____________________________
Type of Account: ______ Checking ______ Savings
If you selected Checking, please attach a copy of a VOIDED check to this form. If you selected Savings, please verify
that your bank allows deductions from saving accounts. For savings accounts, you may also want to obtain a form from
your bank, which includes the bank name, the routing (ABA) number and the account number to attach to this
authorization form.
PAYMENTS WILL BE DEDUCTED ON THE 15
TH
OF THE MONTH YOUR BILL IS DUE
I realize the amount of my utility bills vary per billing period depending on usage and rates. I understand that I will have at
least 5 days to review my bill prior to the deduction being made from my account. Based on the above, I hereby authorize
Waukesha Water Utility to initiate entries to my account at the Financial Institution named on the enclosed voided check,
and authorize that Financial Institution to debit my account for those entries. This authorization will remain in effect until
Waukesha Water Utility has received written revocation by me or my representative at least 30 days in advance of the
next schedule payment. Waukesha Water Utility has the right to cancel this agreement and charge a fee if there are not
sufficient funds in my account.
(Print Name) Signature (Date)
(Print Name) Signature (Date)
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Telephone: (262) 521-5272 ● Fax: (262) 521-5265 ● E-mail: contactus@waukesha-water.com
SERVING WAUKESHA SINCE 1886
PO BOX 1648
Waukesha, WI 53187-1648
This completed form and copy of voided check must be mailed or emailed to the Utility to activate ACH withdrawals.
