EFT Debit Authorization

2. Setup*

   1. New Auto Pay

   1. Change Auto Pay

   1. Cancel Auto Pay

   Choose New or Change to setup an Auto Pay option, choose Cancel to remove an Auto Pay

4. First Name*

5. Last Name*

7. Business Name

   (if applicable)

9. Phone

10. E-Mail

12. ACWWA Account No*

13. Date*
    Date

15. Service Address*

17. Mailing Address

    (if different from above)

19. City*

20. State*

21. Zip*

25. Financial Information
    The EFT Debit Authorization is to remain in full force until ACWWA has received a cancelation notification of its termination. All fields are required to insure the accuracy of the financial information.

    The EFT Debit Authorization is to remain in full force until ACWWA has received a cancelation notification of its termination. All fields are required to insure the accuracy of the financial information.

27. Financial Institution Name*

29. Account Type*

    1. Checking

    1. Savings

30. Account Classification*

    1. Personal

    1. Business

32. Routing Number*

33. Checking Account Number*

37. Authorization*

    This form must be received by the 15th of the current month to start or cancel an Auto Pay. ACWWA will withdraw the funds on the 20th of every month or the closest business day after. A letter of confirmation verifying the EFT will be sent to your address or email provided. By checking this box, you acknowledge and authorize ACWWA to make the above changes to your account.

    1. I Accept
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field