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Automatic Payment Form for MUD District Water/Sewer Bills

AUTHORIZATION AGREEMENT FOR DIRECT WITHDRAWAL PAYMENTS ( ACH DEBIT)

I authorize Municipal Utility District (MUD) to initiate monthly debit entries in the amount of my/our utility bill(s) from the bank account or financial institution identified

below. I/we acknowledge that the origination of ACH debit/credit transactions to my/our account must comply with the provisions of United States law. This authorization

shall remain in full force and effect until one of the following occurrences:

The MUD receives written notification, signed by all parties named below, of the termination of this authorization agreement in such time (minimum of 30 calendar

days preceding the next due date of a utility bill) and manner as to afford the MUD, and the financial institution a reasonable opportunity to act on it.

Utility service registered in name(s) below is terminated and the final bill is paid.

The MUD receives two (2) non-sufficient fund (NSF) notices from the financial institution in any (12) month period. In this situation, the utility customer will be

notified by the MUD of the NSF notices, charged the applicable fee assessed by MUD, and placed on a cash only basis for payment of MUD bills.

Failure of the customer to notify the MUD of a change in financial account information resulting in a NSF/CLOSED ACCOUNT notice will also institute deactivation

of this service.

I/we have submitted this financial account information in confidence to the MUD. I/we are not required by law to provide financial account information—it is provided

solely for participation in this program. MUD has obliged itself to act in good faith not to disclose financial account information.

I/we understand that cancellation/termination of service may require several days to implement and that authorized withdrawals from my/our bank account named below

may occur prior to cancellation of my/our participation in the direct payment program. My/our signature on this form indicates my/our understanding of and agreement to

the MUD Direct Withdrawal Payment Program policies and procedures

Note: All customers wishing to participate in the Direct Withdrawal or the Automatic Credit Card Payment Program must complete, sign, return, and

agree to the terms stated on this authorization agreement as required by Federal Banking Regulations.

PLEASE PRINT YOUR NAME AND ADDRESS AS IT APPEARS FROM YOUR FINANCIAL INSTITUTION

PRINT NAME ON ACCOUNT:

__________________________________________________________________________________

MAILING ADDRESS:

__________________________________________________________________________________

_____________________________________________________________________________________________________

SIGNATURE:_________________________________________________________________ DATE:___________________________

CELL PHONE:_______________________________________HOME PHONE:_____________________________________________

E-MAIL ADDRESS:_____________________________________________________________________________________________

PHYSICAL ADDRESS IF DIFFERENT FROM MAILING ADDRESS: ___________________________________________________

M.U.D. ACCOUNT # ____ ____ - ____ ____ ____ ____ - ____

____ (PLEASE FILL OUT SEPARATE FORMS FOR MULTIPLE ACCOUNTS)

CHOOSE ONE OF THE FOLLOWING AND CHECK THE APPROPRIATE BOX:



DIRECT WITHDRAWAL FROM BANK ACCOUNT

CHECKING

SAVINGS

***PLEASE ATTACH A VOIDED CHECK FOR THIS OPTION***

NAME OF FINANCIAL INSTITUTION:___________________________________________________________________

BANK ACCOUNT NUMBER:___________________________________________________________________________

ABA ROUTING NUMBER:_____________________________________________________________________________



AUTOMATIC PAYMENT TO CREDIT CARD

MASTERCARD

VISA

AM EX

DISCOVER

CREDIT CARD NUMBER: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

EXPIRATION DATE (MM/YY): ___ ___ / ___ ___

CVC __ __ __ __

The draft will not take effect until the next billing cycle, please confirm that all outstanding balances are paid

to avoid any late fees or interruption of service.

**** To send this form, call for an email at 281-367-1271 or fax to 281-298-7216.****

Commercial Water-Sewer Service Application And Automatic Draft Forms - The Woodlands Joint Powers Agency Page 2

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