Automatic Bill Payment
Authorization Form

I authorize the Monroe County Water Authority to begin electronic deductions from my chosen checking account for payment of my water bill.

I understand that the Automatic Bill Payment plan is an alternative method of payment only and does not otherwise affect the respective rights of the Authority or my financial institution, with respect to each other or myself. I also understand that the Authority and my financial institution reserve the right to terminate this payment plan and/or my participation in it. It is my responsibility to notify the Authority if I change my checking account number or if I choose to cancel participation in the Automatic Bill Payment plan.

 

Name of Financial Institution: 
Checking Account Number: 
Customer Name: 
Service Address: 
City 
Zip Code 
Phone Number 
E-Mail: 
Water Bill Account Number:
Date:
Signature:
__________________________________

print the completed Authorization Form and sign
print a second copy of the authorization form for your records
write the word "VOID" on a blank check (pre-printed with name and address)
send the completed form and the voided check to:

Attention: Customer Service
Monroe County Water Authority
P.O. Box 10999
Rochester, N.Y. 14610-0999

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