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Authorized Agreement for Direct Debit Payment I hereby authorize and request the City of Ar- vada (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) indi- cated 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 cor- rectness of entries. City of Arvada Account Number Customer Name Service Address State Zip Phone # It is understood and agreed that I may withdraw from participation at any time by notifying Util- ity Billing in written form at least five busi- ness days before the due date, notification shall be effective upon receipt. Customer Signature Date Please check the type of account you are using: ! Checking Account ! Savings Account Banking Institution Bank Routing Bank Account # (A voided check must be included to process the application)