Bank Auto Draft Form

WEST KNOX UTILITY DISTRICT
Bank Auto Draft Form

I (we) hereby authorize West Knox Utility District to initiate debit entries to such account by funds transfer for payment of my monthly utility bill. This authorization is to remain in effect until I notify West Knox Utility District that I wish to end this agreement and West Knox Utility District has had reasonable time to act on it; or until West Knox Utility District has sent me written notice that they will end this agreement. I understand that West Knox Utility District will continue to send me a monthly statement and I must notify West Knox Utility District a minimum of five (5) days prior to the draft date with any discrepancies. I further understand that in the event my account has insufficient funds or my monthly draft is rejected due to a closed account, West Knox Utility District will assess an amount equal to the maximum set forth by the TCA when collecting the funds. It my responsibility to notify West Knox Utility District fifteen (15) days prior to a scheduled debit of any changes made to my designated depository account. Including but not limited to closed status, bank ownership changes and account changes. Furthermore, I attest I am an authorized owner of the Depository Account listed below, and am exercising my powers as such.

ACCOUNT INFORMATION

WKUD Account Number *

Service Address *

Are you the account holder? *

Yes

Due Date Of Bill *

Last Name On Account *

First Name *

M.I. *

Email *

Phone *

INFORMATION IF NOT ACCOUNT HOLDER

Relationship to the Account Holder *

Last Name (If Different From Account Holder) *

First Name *

M.I. *

Email *

Phone *

BANK INFORMATION

Bank Account Type *

Name Of Bank *

Bank Routing Number *

Bank Account Number *

Start Date For Autodraft To Begin * +

Date Submitted * +

By checking the box below I authorize West Knox Utility District to draft the amount of my monthly utility bill from the financial institution listed above. I understand that my account will be drafted on the due date indicated on each monthly statement. *

Yes, I give authorization.