AUTOMATIC WATER BILL PAYMENT REQUEST

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ELECTRONIC WITHDRAWAL REQUEST FOR
BROWNSTOWN WATER BILLINGS ONLY
The Charter Township of Brownstown DPW offers the opportunity to pay
your Water Bill utilizing our Electronic Bill Payment Service, at no charge.
Once enrollment is processed your water bill will show the following
information “ACCOUNT SCHEDULED FOR ELECTRONIC PAYMENT
DONOT PAY” with amount to be deducted and the deduction due date.
Upon receipt of this form fully completed and signed you will be
authorizing Brownstown DPW to electronically withdrawal your current
water bill payment from either a checking and/or saving account you
authorize.
Complete the contact information request (PLEASE PRINT)
Name (as shown on your checking/saving account must be same names on water account)
Service Address: ___________________________________________________
Account # (as shown on your water bill) (Example 00-00-00000-0
City________________________
State_______
Zip____________
Phone number you can be reached at:
Home: (
) __________________ Cell: (
) _____________________
Provide your signature for authorization:
I authorize the company indicated to deduct my water
billing payment(s) from the checking and/or savings account listed. I understand that I control my payments and if at any
time I decide to discontinue this payment service I will notify said company in writing. I also understand that all
information will remain confidential.
THIS FORM CANNOT BE PROCESSED WITHOUT YOUR SIGNATURE
(SIGNATURE
DATE
Provide the required financial information below:
To ensure the correct account
number and correct ABA/routing number to be used submit a voided check or contact your financial
institution for assistance.
Name of Financial Institution: _____________________________________________
ABA/Routing Number: ___________________________________________________
Checking Account Number: _______________________________________________
Saving Account Number: _______________________________________________
Any questions please call 734-675-4000 during regular working hours 8:00 am –
4:25 pm or send email to: [email protected]
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