Bank Authorization Discontinue
Cycle:_____
Clark-Edgar Rural Water District
475 IL Hwy 1, P.O. Box 297, Marshall, IL 62441
1-800-966-5888 or 217-463-5888
Authorization to Discontinue Automatic Withdraw Payments
I (we) request/authorize that Clark-Edgar Rural Water District discontinue the automatic payments from being withdrawn from my (our) account effective the date of this request. I (we) understand that I (we) will need to continue paying our water bills to avoid late fees and any fees associated with the water being disconnected due to nonpayment. I (we) understand that if I (we) would like to start having our payments automatically withdrawn, then a new authorization form will need to be filled out.
CERWD Account Number: _______________________________________________
Name on Account: ______________________________________________________
Address: ______________________________________________________________
City: __________________________ State: ________ Zip: ____________
Bank Name: __________________________________________________________
Address: ______________________________________________________________
City: ___________________________ State: ________ Zip: ____________
Account Number: _______________________________________________________
Transit Routing Number: _________________________________________________
Type of Account: Checking _________ Savings _________
Date: _______________________
Signature(s): ___________________________________________________________
Print Name(s): __________________________________________________________