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Automatic Debit Authorization Form

  1. Instructions:

    Please complete fillable fields. Then print, sign and fax to 520-822-8850, or mail to Sahuarita Wastewater, 375 W. Sahuarita Center Way, Sahuarita, AZ 85629. The information entered into this form is for printing purposes only. It cannot be submitted over the internet, and it is not saved or maintained except when the printed form is submitted by fax or mail to Sahuarita Wastewater.

  2. IMPORTANT NOTICE: Funds will be drawn monthly on the 20th.

  3. Payment Authorization

    I authorize my bank to debit my account as identified above to the terms stated here. This authorization shall remain in effect until the Service Provider receives written notification from me of intent to terminate at such time and in such manner as to afford the Service Provider reasonable opportunity to act (Minimum 30 days). I understand that the amount owed to the Service Provider may increase or decrease from one billing period to another, and I authorize this plan to continue with the payment amount increased or decreased accordingly until the amount owed the Service Provider is paid off, unless the plan is terminated earlier by me as above. I also understand that the date that my account will be charged shall be determined by the Service Provider, and is subject to change without notice. Any change to my customer address or bank account will require a new Automatic Debit Authorization Form to be filled out and submitted to Merchant 15 days prior to any change being implemented. I understand that this payment plan may be cancelled by the Service Provider or Merchant due to NSF (Non-sufficient Funds). I will be liable to pay an NSF fee of $30.00 (or the amount allowable by law), which may be automatically debited for each NSF. I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this payment plan. I indemnify and hold the Service Provider, the bank, and Merchant harmless from damage, loss or claim resulting from all authorized actions hereunder.

  4. Payment Authorization Acknowledgment*

    I have read and understand the payment authorization information above.

  5. Please print form, sign and fax to 520-822-8850, or mail to Sahuarita Wastewater, 375 W. Sahuarita Center Way, Sahuarita, AZ 85629.

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