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Bank Draft Authorization Form

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BANK DRAFT AUTHORIZATION FORM
City of Haslet Utility Billing Department 101 Main Street Haslet, TX 76052 (817) 439-5931
You must attach a VOIDED Check.
All Information must be completed.
Accounts will be drafted on the due date printed on your utility bill.
I hereby authorize the City of Haslet to debit my checking account monthly for my water utility bill. This authority is to remain in full force and effect until the City of Haslet has received written notification from me of its termination in such time and in such manner as to afford the City of Haslet and the banking institution a reasonable opportunity to act upon it.
PLEASE DEBIT MY ACCOUNT FROM THE BANKING INSTITUTION AND ACCOUNT NUMBER SHOWN BELOW.
Haslet Utility Billing Account Number (if available)
Customer Name
Service Address
Home Telephone Number
Cell Phone Number
Bank Name
Bank Routing Number
Bank Account Number
Do you wish to donate $1 monthly to the Parks and Recreation Board & Library Board?
1. Yes
1. No
ACCOUNT AUTHORIZATION SIGNATURE:
Print this form and sign.
DATE
DATE
NOTE: THIS FORM MUST BE PRINTED, SIGNED, AND SUBMITTED TO THE UTILITY BILLING DEPARTMENT WITH A VOIDED CHECK FOR PROCESSING. MAY BE DROPPED OFF OR MAILED TO THE CITY OF HASLET, 101 MAIN ST., HASLET, TX 76052.