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2. Draft Authorization Form

4. Name of Financial Institution*
6. Bank Account Number*
7. Transit/ABA Number*
8. Upload a copy of a Voided Check

   You can take a picture of the check and upload it here.

10. Until revoked in writing, I hereby authorize you to pay bills for me, provided sufficient funds are on deposit to my credit, when presented by the following: 

    (plus you service charge therefore, if any)

12. Utility Account Name*
13. Utility Account Number*
14. Additional Utility Account Number
16. Service Address*
18. Mailing Address
20. City
21. State
22. Zip Code
24. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature
27. Today's Date
    Today's Date
Leave This Blank:


29. Submit

* indicates a required field