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! ! Authorized Agreement for Direct Debit Payment I hereby authorize and request the City of Arvada (City) to receive payments of amounts owed by me for City water and sewer charges by initiating on the due date debit entries to my account at the Banking Institution (Bank) indicated below. I hereby authorize and request Bank to accept debit entries initiated by City and to debit the same to my account without liability for the correctness of entries. City of Arvada Account Number Customer Name Service Address Zip Phone It is understood and agreed that I may withdraw from participation at any time by notifying Utility Billing in written form at least five business days before the due date, notification shall be effective upon receipt. Customer Please check the type of account you are using: ! Checking Account ! Savings Account (A voided check must be included to process the application) Banking Bank Routing Bank Account Mail to: City of Arvada 8101 Ralston Road Arvada, CO 80002 SIGN