You are invited to join GreensvilleCounty Water & Sewer Authority’s convenient, automatic draft for payment of utility bill. Your checking or savings account will be drafted on the 10th of each month or next business day. Each transaction is recorded as a deduction on your bank statement.

HOW TO ENROLL

Complete and sign the authorization form inside this brochure

Provide a blank check marked “VOID” or

a deposit/withdrawal slip from savings account

Return the form and voided document to the address below

IMPORTANT TO NOTE

DRAFT WILL NOT OCCUR UNTIL NEXT BILLING CYCLE

STATEMENT WILL SHOW “Auto Draft on (date)”

Deduction will be on 10th or next business day.

DRAFT WILL BE FOR TOTAL DUE ON UTILITY BILL

The Greensville CountyWater

Sewer Authority is dedicated to

serving the needs of all Greensville

County citizens. If you need more

information, give us a call. We will

do our best to answer your questions.

GreensvilleCounty

Water & Sewer Authority

1781 Greensville County Circle

Emporia, Virginia23847

(434) 348-4213

(10/01/08)

GREENSVILLE

COUNTY

WATER

SEWER

AUTHORITY

GCWSA

APPLICATION

FOR

AUTOMATIC

DRAFT

FOR PAYMENT

OF

UTILITY BILL

GREENSVILLECOUNTY WATER & SEWER AUTHORITY

AUTHORIZATION AGREEMENT

AUTOMATIC DRAFT

FOR PAYMENT OF UTILITY BILL

I (we) hereby authorize and request the Greensville County Water & Sewer Authority to initiate electronic debit entries or affect a charge by any accepted practice to my (our) account indicated below in the financial institution named below (“BANK”) and I (we) authorize and request BANK to honor the debit entries initiated by the Greensville County Water & Sewer Authority and debit the same from my account*. This agreement pertains to my (our) utility account number and said contract. This authorization is to remain in force and effect until the Greensville County Water & Sewer Authority and BANK have received written notification from me (or either of us) of its termination in such time and such manner as to afford the Greensville County Water & Sewer Authority and BANK a reasonable opportunity to act on it.

Date ______

Customer Name ______

Utility Customer Number ______

BANK ______

Bank Address ______

______

City, State, Zip

Bank Routing Number ______

Bank Account # ______Checking or Savings (circle one)

SIGNATURE (S) ______

______

(All account depositors must sign if more than one

signature is required on that account)

* DRAFT WILL OCCUR ON THE 10TH OF THE MONTH OR NEXT BUSINESS DAY

(If a payment is due on a weekend or holiday, the Greensville County Water & Sewer Authority will initiate a debit entry and credit your utility account on the next business day.)