Bank Draft Authorization Form

1. Customer Information(current) This section is complete This section is incomplete
2. Financial Institution Information This section is complete This section is incomplete
3. Acknowledgements This section is complete This section is incomplete

Customer Information

Bank Name*
Bank Routing #*
Bank Checking Account #*
Upload Voided Check*
A voided check or a letter from the financial institution, on company letterhead, verifying the applicant's routing/transit and account numbers, is required to begin the bank draft.
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Acknowledgements*
1. I certify that the financial information above is correct, that I am an authorized signer or designate on the account provided for ACH/EFT transactions, and that I am authorized to provide this information.
2. I acknowledge that Pelham Water Works reserves the right to cancel Electronic Fund Transfers due to insufficient funds without notice.
3. I authorize Pelham Water Works to deduct my utility payments from this bank account via Electronic Funds Transfer. I understand a written notification to Pelham Water Works is required to cancel or stop this authorization. A new Bank Draft Authorization Form will be required to make changes or reinstate authorization to draft.
The City of Pelham does not provide or restore water service to an existing property with an unpaid balance.
Electronic Signature*
This electronic signature is intended to be the legally binding equivalent of a handwritten signature. By signing electronically, you acknowledge and agree that your electronic signature carries the same legal weight, validity, and enforceability as a traditional handwritten signature under applicable laws and regulations, including the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN Act) and the Uniform Electronic Transactions Act (UETA).
If you do not wish to sign electronically, please contact us for alternative signing methods.

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