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Phillip Dean Kris Stancil Director of Utilities Commissioner Chairman DISCONTINUE AUTOMATIC DRAFT I would like to stop the automatic draft on my account as of (Month, Day, Year) Account Name: (Name as shown on your Billing Account) Address: City, State, Zip: Home Phone: Cell Phone: Financial Institution: Checking Account Financial Institution Routing Number: (This number is located between these symbols I:I on the bottom left of your check.) Signature: Date: This request may take 30 days from both the Bank and our establishment to process. Failure to allow the requested time may result in a returned check in which you will be responsible for. Our office will keep this form as proof of your request to discontinue the Automatic Draft. 1266 East Church Street Phone: [PHONE REDACTED] Jasper, GA 30143 Fax: 7066-253-8720 SIGN