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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) PCW&SA Account Name: (Name as shown on your Billing Account) Address: City, State, Zip: Home Phone: Cell Phone: Name of Financial Institution: Checking Account Financial Institution Routing Number: (This number is located between these symbols I:I on the bottom left of your check.) Please include a copy of your driver’s license for verification with this request to discontinue the Automatic Draft. This request may take 30 days from both the Bank and our establishment. 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. Signature: Date: 1266 East Church Street Suite 117 Jasper, GA 30143 Phone: [PHONE REDACTED] FAX: [PHONE REDACTED] SIGN