Automatic Bank Draft and Bank Draft Cancellation

Authorization Agreement To:

Start Pre-Authorized Payment

Stop Pre-Authorized Payement

Depository Name(Required)

First Last

Bank Name(Required)

First Last

Bank Address(Required)

City State ZIP Code

Routing Number(Required)

Account Number on Bank Account(Required)

Month to Begin Drafts

Month to End Drafts

Name on Account(Required)

First Last

Drivers License(Required)

Please submit a copy (front and back) of your valid drivers license.

Max. file size: 64 MB.

Riverside SUD Account Number(Required)

This authorization will remain in effect until I/we notify Riverside Special Utility District and my/our financial institution in writing of its cancellation. Notice must be provided in a timely manner that allows both parties a reasonable opportunity to process and act on the request.

Customer Signature(Required)

Use your finger or mouse to sign this agreement. Please note that electronic signatures are binding