HONEY GROVE WATER DEPARTMENT

AUTHORIZATION TO DRAFT MONTHLY WATER BILL

WATER BILLS ARE DRAFTED ON THE 3^RD OF EACH MONTH

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AUTHORIZED NAME/NAMES ON ACCOUNT

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BANK ACCOUNT NUMBER      

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ROUTING NUMBER

HONEY GROVE WATER DEPT.

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BANK TO BE DRAWN ON                                                   

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                             ADDRESS

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           CITY  -  STATE  -  ZIP CODE

I hereby request and authorize you to pay and charge to my account, debits drawn by the drawer, stated above, The City of Honey Grove Water Department, to its own order.  This authorization will remain in effect until revoked by me in writing, and until you actually receive such notice.  I agree that you shall be fully protected in honoring any such debit.

I agree that your treatment of each such debit and your rights in respect to it, shall be the same as if it were signed personally by me.  I further agree that if any such charge be dishonored, whether with or without cause, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of consideration or benefits of membership or subscription.

The drawer, City of Honey Grove Water Department, is instructed to forward this authorization to you.

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  Account Holder’s Signature                                                    Date

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 Spouse’s Signature (If on Account)                                       Date