AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS

I hereby authorize The Village of Waterville to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my account listed below.

Name of Financial Institution ______________________________

City and State ______________________________

Transit/ABA Number ______________________________

Account Number ______________________________

Circle One: Checking or Savings

This authorization is to remain in full force and effective until The Village of Waterville has received written notification from me of its termination in such time and in such manner as to afford The Village of Waterville and the Financial Institution a reasonable opportunity to act on it.

Water Account Number____________________________

Address____________________________

Name_______________________________________________

Signed________________________________________________

Date________________________________________________

*Please attach a Voided Check or Savings Deposit Slip for the account listed.*

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