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GERMAN TOWNSHIP WATER DISTRICT, INC.

2636 W BOONVILLE-NEW HARMONY RD.

EVANSVILLE, IN 47720-7523

Phone - (812) 963-6403

AUTHORIZATION AGREEMENT FOR DIRECT DEBIT

(automatic monthly payments)

GERMAN TOWNSHIP WATER DISTRICT, INC

I hereby authorize German Township Water District, Inc., hereinafter called COMPANY, to initiate Direct Debit entries and necessary credit entries for adjustments to correct errors to my CHECKING or SAVINGS ACCOUNT indicated below at the depository name below, hereinafter called DEPOSITORY.

DEPOSITORY NAME (Bank Name)

TRANSIT/ABA NO. (Routing No.)

ACCOUNT NO. (Bank Acct #)

Account Type

Checking

Savings

This authority is to remain in full force and effect until COMPANY has received written or verbal notification from me of its termination and in such manner as to afford COMPANY AND DEPOSITORY a reasonable opportunity to act on it.

First name

Last name

Phone

Address

GTWD ACCOUNT NUMBER (s)

Today's Date

Month

Day

Year

Signature

In lieu of a physical voided check or deposit slip, by clicking agree it signifies verification that the routing number and bank account number provided is correct

***PLEASE NOTE***

There will be a $42.00 charge for all returns.

After 3 returns, your Direct Debit Agreement will be terminated

The water bill payment will run automatically on the 10th day of every month.

I would like to sign up for electronic billing. (I agree to the terms of GTWD automatic payments and understand I will be placed on E-Billing therefore will no longer receive a bill by mail.)

Yes

I agree to the terms of GTWD automatic payments.