Automatic Bank Drafting Service Authorization Letter

Dear Sir/Madam:

Please accept this as your authority to pay against my account each month a draft drawn by the City of Washington for my utility bill. The amount of this draft will vary according to the amount of my bill. I understand that my account will be drafted on the due date as stated on the bill.

(Please Print)

Last Name: __________________________________First Name:_________________ MI:______

Washington Utilities Acct #___________________________ Phone No.: ____________________

Address: ________________________________________________________________________

City: _____________________________________State:_________________ Zip:_____________

Bank Name:____________________________________ Bank Acct. #:______________________

Location: _________________________________Transit #:_______________________________

You are hereby authorized to draw a bank draft for the payment on my monthly utility bill.

Signature: ___________________________________________Date:_______________________