Decatur Township - Clearfield County

                              AUTOMATED WITHDRAWAL FOR SEWAGE PAYMENTS

Decatur Township 575 Fairview Road Osceola Mills, Pa 16666 **814-339-6772 Phone ** 814-339-7240 Fax 

Automated Withdrawal Form

Monthly Sewer Payment 

Your Name: __________________________________________________________

 

Address: _____________________________________________________________

 

Account Number:__________________________________________________

 

Phone Number: _______________________________________________

 

Bank Information:

 

Bank Name: ___________________________________________________________

 

Routing Number: _______________________________________________________

 

Account Number:_______________________________________________________

 

Is this a (Circle One):    Checking   or    Savings 

      Choose a day for the Auto-Withdrawal (Circle One):     15th   or    30th 

I hereby grant permission to Decatur Township to Automatically Withdrawal from the account provided for my Monthly Sewer Bill Payment of $32.00 per ERU on the date provided. This will remain in affected until the client terminates this transaction. If an error occurs in the transaction amount, I herby authorize Decatur Township to initiate a correcting transaction to/from the account indicated. If at any time the Sewer Rate is increased then the amount withdrawn will increase. Decatur Township is not responsible for any overdrafts that occur when inadequate funds are available the day of the withdrawal. 

__________________________________                                   __________________________________________

Signature                                                                                         Print Name 

_____________________________                                            _________________________________________

Date                                                                                                I hereby terminate this transaction:  Signature/Date

 

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