ARIZONA CITY SANITARY DISTRICT

   PO BOX 2377  12922 S KASHMIR RD. ARIZONA CITY, AZ 85123

   OFFICE: (520) 466-5203  FAX: (520) 466-5849  e-mail: acsdinfo@azcitysewer.net

Make this your LAST check!

Sign up for automatic bill pay drafting.  Funds to pay your sewer bill will automatically be taken from your account.

Choose an easy AutoPay option:

___ Electronic Funds Transfer (EFT) Checking   (Include Pre-Printed VOIDED check)

                                   Or

___ Electronic Funds Transfer(EFT) Savings        (Include VOIDED deposit slip)

Authorization Agreement for Direct Payments (ACH Debits):

Name:  ________________________________________________________________

Mailing address:  ________________________________________________________

City/State/Zip:  _________________________________________________________

Phone Number:  ________________________________________________________

Sanitary District Account #:  ______________________________________________

This authorization is to remain in full force and effect until the Arizona City Sanitary District has received written notification from me (or either of us) of its termination in such time and in such manner to afford the Arizona City Sanitary District and it’s financial institution a reasonable opportunity to act on it.  I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U. S. law.

I authorize the Arizona City Sanitary District or the financial institution to automatically debt my checking or savings account for the total amount due on my account for sewer fees.  I understand if the transaction is returned by my financial institution for any reason, return check charges may apply.  I also agree to contact the Arizona City Sanitary District at least (7) days before the end of the month with any concerns to allow time for correction.  I understand that by authorizing automatic bill pay drafting, I will no longer receive a monthly statement of my but that I may obtain a copy of my monthly statement at the Arizona City Sanitary District.

Date:  __________________    Signature: _____________________________________

NOTE:  Debt authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization

ACSD Form Rev 08/2009