You are invited to join GreensvilleCounty Water & Sewer Authority’s convenient, automatic draft for payment of utility bill. Your checking or savings account will be drafted on the 10th of each month or next business day. Each transaction is recorded as a deduction on your bank statement.
HOW TO ENROLL
Complete and sign the authorization form inside this brochure
Provide a blank check marked “VOID” or
a deposit/withdrawal slip from savings account
Return the form and voided document to the address below
IMPORTANT TO NOTE
DRAFT WILL NOT OCCUR UNTIL NEXT BILLING CYCLE
STATEMENT WILL SHOW “Auto Draft on (date)”
Deduction will be on 10th or next business day.
DRAFT WILL BE FOR TOTAL DUE ON UTILITY BILL
The Greensville CountyWater
Sewer Authority is dedicated to
serving the needs of all Greensville
CountyCitizens. If you need more
information, give us a call. We will
do our best to answer your questions.
GreensvilleCounty
Water & Sewer Authority
1781 Greensville County Circle
Emporia, Virginia23847
(434) 348-4213
(10/01/08)
GREENSVILLE
COUNTY
WATER
SEWER
AUTHORITY
GCWSA
APPLICATION
FOR
AUTOMATIC
DRAFT
FOR PAYMENT
OF
UTILITY BILL
GREENSVILLECOUNTY WATER & SEWER AUTHORITY
AUTHORIZATION AGREEMENT
AUTOMATIC DRAFT
FOR PAYMENT OF UTILITY BILL
I (we) hereby authorize and request the Greensville County Water & Sewer Authority to initiate electronic debit entries or affect a charge by any accepted practice to my (our) account indicated below in the financial institution named below (“BANK”) and I (we) authorize and request BANK to honor the debit entries initiated by the Greensville County Water & Sewer Authority and debit the same from my account*. This agreement pertains to my (our) utility account number and said contract. This authorization is to remain in force and effect until the Greensville County Water & Sewer Authority and BANK have received written notification from me (or either of us) of its termination in such time and such manner as to afford the Greensville County Water & Sewer Authority and BANK a reasonable opportunity to act on it.
Date ______
Customer Name ______
Utility Customer Number ______
BANK ______
Bank Address ______
______
City, State, Zip
Bank Routing Number ______
Bank Account # ______Checking or Savings (circle one)
SIGNATURE (S) ______
______
(All account depositors must sign if more than one
signature is required on that account)
* DRAFT WILL OCCUR ON THE 10TH OF THE MONTH OR NEXT BUSINESS DAY
(If a payment is due on a weekend or holiday, the Greensville County Water & Sewer Authority will initiate a debit entry and credit your utility account on the next business day.)