Bank Authorization Discontinue


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I (we) request/authorize that Clark-Edgar Rural Water District discontinue the automatic payments from being withdrawn from my (our) account effective the date of this request.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 I (we) understand that if I (we) would like to start having our payments automatically withdrawn, then a new authorization form will need to be filled out.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): __________________________________________________________