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2. Coldwater Board of Public Utilities Authorization for Automatic Bill Payment
4. I (We) hereby authorize Coldwater Board of Public Utilities, hereinafter called Company, to initiate debit entries to my Checking/Savings account* indicated below and the Financial Institution named below, hereinafter called bank, to debit the same to such account.
6. Bank Name*
7. City/State*
9. Transit/ABA Number*
10. Acct Number*
12. Acct Type*

    1. Checking
    2. Savings
13. First Effective Date*
    First Effective Date
15. This authority is to remain in full force and effect until company has received written notification from me of its termination in such time and in such manner as to afford Company a reasonable opportunity to act on it.
17. Name (as shown on your bill)*
19. Customer #*
20. Daytime Phone
22. Service Address*
24. City*
25. State*
26. Zip*
28. Mailing Address (if different)
30. Image of Bank Information*
    Please attach a photo of a voided check or savings account deposit slip signed with your signature.
32. Digital Signature*

    I acknowledge that I have read, understand, and will abide by the procedures above.

    1. I Acknowledge.
33. Date*
    Date
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field