Bank Draft Authorization

Bank Draft Authorization

Automatic Payment Plan

CUD Account Number*
Located on Bill - Ex. 9999999-01
Type*
Name on your Utility Bill*
Last 4 digits of your Social Security Number*
Effective Date*
Date Format: MM slash DD slash YYYY
Phone Number*
Email Address*
Bank Name*
Checking Account Holder's Name*
Bank Routing Number*
Checking Account Number*
Terms of Service
Required*
- I agree to the Terms of Service