consumer_authorization_form.pdf
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This is the Town of Centreville Authorization Agreement for Preauthorized Payments. It authorizes the Town Council of Centreville to initiate debit (ACH) entries to the customer’s checking account and requires the customer to provide bank name, branch, city/state/zip, transit/ABA routing number, account number and a voided check or deposit slip. The authorization remains effective until the Town and bank receive written termination; the form also collects customer name(s), service address, date, phone, email and signature lines.
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The Town of Centreville 101 Lawyers Row Centreville, MD 21617 410-758-1180 fax 410-758-4741 www.townofcentreville.org AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS CUSTOMER NAME (S) ______________________________________________________ I (we) hereby authorize Town Council of Centreville, hereinafter called COMPANY, to initiate debit entries to my (our) Checking account indicated below and the financial institution named below, hereinafter called BANK, to debit the same to such account. BANK NAME ____________________________________________________ BRANCH ______________________________________________ CITY _____________________________ STATE ___________ ZIP ___________________ TRANSIT/ABA/ROUTING NO. _______________________________________ ACCOUNT NO. _________________________________________ A voided check or deposit slip is required to accompany this form. This authority is to remain in full force and effect until COMPANY and BANK 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 BANK a reasonable opportunity to act on it. CUSTOMER NAME (S) ________________________________________________________ (PLEASE PRINT) SERVICE ADDRESS __________________________________________________________ DATE _____________________PHONE NUMBER __________________________________ EMAIL ______________________________________________________________________ SIGNED ________________________________ SIGNED ____________________________