BANK DRAFT AUTHORIZATION (ACH DEBITS)

I (we) hereby authorize CITY OF BASTROP, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account / Savings Account (select one) indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Name of Bank (Print):
City:
State: Zip:
Routing Number:
Account Number:

PLEASE ATTACH A VOIDED CHECK TO THIS FORM.

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and Depository a reasonable opportunity to act on it.
Name(s) (as on bank account):
Utility Bill Account Number(s):
Date:

SIGNATURE (as accepted by bank): _____________________________________

Any account that comes back with insufficient funds will no longer be allowed to participate in the Bank Draft Program.

NOTE: DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.