DIRECT PAYMENT AUTHORIZATION FORM
PLEASE PRINT AND SEND TO US
HERE IS HOW THE DIRECT PAYMENT PLAN WORKS: You authorize regularly scheduled payments to be made from your checking account or savings account. Your payments will be made automatically on the 15th day of the month and proof of payment will appear on your statement.
The authority you give to charge your account will remain in effect until you notify us in writing to terminate the authorization. If the amount of your payment changes we will notify you at least 10 days before payment date. The Direct Payment Plan is dependable, convenient, and easy. To take advantage of the service, complete the attached authorization form and return it to us.
1) Mark the box before type of account to indicate whether your payment will be deducted from your checking or savings account.
2) Fill in your name, financial institution name and location, and date.
3) Attach a voided check for verification of all financial institution information.
NOTE: Be sure to sign the form!
Please complete the information below
DATE____________________________________
I ,authorize Neal's Water Conditioning Inc. to initiate electronic debit entries to my:
_____Checking account (or) _____Savings account
for payment of my NEALS WATER CONDITIONING bill.
Address
FINANCIAL INSTITUTION NAME(PLEASE PRINT)___________________________
ACCOUNT NUMBER AT FINANCIAL INSTITUTION____________________________
FINANCIAL INSTITUION ROUTING NUMER_________________________________
FINANCIAL INSTITUTION CITY AND STATE______________________________
I ACKNOWLEDGE THAT THE ORIGINATION OF ACH TRANSACTIONS TO MY ACCOUNT MUST COMPLY WITH THE PROVISIONS OF U.S. LAW.THIS AUTHORITY WILL REMAIN IN EFFECT UNTIL I HAVE CANCELLED IT IN WRITING.
SIGNATURE__________________________________________________________
OFFICE USE ONLY
NEAL'S ACCOUNT #__________ ACCOUNT TYPE____________________ NEXT BILLING MONTH__________
DATE TO BEGIN ACH________________ ADDITIONAL ACCOUNT COMMENTS____________________________________
