Bank Draft Enrollment Form

ACH DRAFT PAYMENT Now Available Payment by Bank Draft Simplify Your Life Avoid missing your Bill Due Date! Sign up is easy. Complete the requested information below and submit this form along with a VOIDED CHECK from your checking / saving account. If you do not have a check be sure to PRINT CLEARLY your banking information. Your account will be debited on the 1st day of each month for Madison County and Creola; and the 15th day of each month for Vinemont and Cullman; except for weekends, holidays, etc., at which time processing will take place on the next business day. You will still receive your monthly billing statements as a reminder of the balances being drafted.

AUTHORIZATION FOR BANK DRAFT (ELECTRONIC FUNDS TRANSFER)

Customer #:

Your Name:

Email Address:

Service Address:

Telephone Number:

Find the Routing Number on a Check. At the bottom of a check, you will see three groups of numbers. The first group is your routing number.

Your Bank Routing #:

Find the Account Number on a Check. At the bottom of a check, you will see three groups of numbers. The second is your account number.

Your Bank Account #:

Bank Name:

Please check one:

CheckingSavings

I understand any payment refused by my bank will be handled the same as an “insufficient funds” check (NSF) and charged an overdraft fee of $30.00 After two refused payments by my bank, the Bank Draft payment will be cancelled and my account will be put on “cash only” status for one year, from the date of third return.

Signature below indicates acceptance of these terms and conditions.

Signature:

Date Signed:

If you prefer you can save the Bank Draft Enrollment Form to your computer for printing or emailing. Return the form to info@integrawater.com OR mail it to: Integra Water, LLC PO Box 10127 Birmingham, AL 35202