Bank Draft Form

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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

Today's Date *

Customer Name *

Customer Number

Service Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Depository Bank Name *

Bank City *

State *

Zip Code *

Routing No. *These numbers must be taken from a check – NOT a deposit slip.

Account No. *

Copy of Voided Check:

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File size limit: 13 MB. Your application will not be complete until you have either uploaded a copy of your voided check here or emailed it to customerservice@lcwsa.com.

I (we) do hereby authorize the above named company, hereinafter referred to as “the company,” to initiate debit entries to my (our) bank account indicated below, hereinafter called “Depository,” and debit the same to such account. This authority is to remain in effect until the company has received WRITTEN NOTIFICATION from me (or either of us) of its termination in such time and in such a manner as to afford the company and bank of depository a reasonable opportunity to act upon it. I understand I will receive my regular monthly bill and the amount shown on the bill will be debited on the due date each month. If my due date is on a weekend or holiday, my account will be debited the following business day. I understand if my debit is returned by the bank for insufficient funds, it is my responsibility to contact the company and make arrangements to ensure payment. If the debit is returned account closed, I understand my service will be subject to immediate disconnection. *I/we accept these terms.

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