Town of Louisville Water Department – Direct Debit Plan – Enrollment Form
Town of Louisville Water Department is please to offer a new service – The Direct Debit
Payment Plan. Now you can have your payment deducted automatically from your
checking account.
Please complete the following information and return this form to: Town of Louisville
Please include a blank VOIDED check.
14810 SH 37
Massena NY 13662
Attn: Direct Debit
(Please print all information)
Name as it appears on your Town of Louisville Water bill: ________________________
Town of Louisville service address: __________________________________________
_______________________________________________________________________
Tax map number: _________________________________________________________
Your mailing address: _____________________________________________________
City: _________________________ State: ____________________ Zip:____________
Daytime Phone Number: __________________________
I authorize The Town of Louisville to begin electronic deductions from my checking
account for payment of my regular Town of Louisville Water bills. I will notify the
Town of Louisville immediately if I change banks or checking accounts or if I want to
cancel this service.
Signature of Bank Account Holder: _____________________________ Date: ________
-------------------------------------------------------------Keep this portion for your records – Date submitted to The Town of Louisville ________
Please watch your bill “DO NOT PAY – DIRECT DEBIT on mm/dd/yy” will appear
on your bill when the program starts.