Bank Draft Form - Town of Landis, NC

Bank Draft Authorization Form

Authorization Agreement for Electronic Transfer of Funds via Bank Draft Debits. Instructions: Please complete this entire form and click submit. An image or pdf of a voided check from your account will be required before submitting the form. This agreement may be revised or terminated at any time by written notification or by resubmitting the form to the Tow of Landis Utility Services.

Check all appropriate box(es):(Required)

New Enrollment/Authorization

Change Bank Account Info

Discontinue

Your Information

Name(Required)

First Last

Utility Account Number(Required)

Your Address(Required)

Street Address City State ZIP Code

Your Phone Number(Required)

Email(Required)

Enter Email Confirm Email

Checking Account ACH Debit Authorization

Please see graphic below for examples where to locate routing code and account number on check.

Start Date(Required)

End Date

Routing Code(Required)

First nine digits, located on the bottom of check.

Account Number(Required)

Thirteen digits following Routing Code.

Scanned/Photo of Voided Check(Required)

Max. file size: 300 MB.

Date Submitted(Required)

Bank Draft Authorization Form

Your Information

Checking Account ACH Debit Authorization

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