AUTO PAY APPLICATION
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NAME *
SERVICE ADDRESS *
MAILING ADDRESS (STREET ADDRESS, CITY, STATE, ZIP) *
WOULD YOU LIKE TO RECEIVE YOUR MONTHLY BILL BY EMAIL OR PAPER BILL? *
PHONE # *
GREENSBURG MUNICIPAL WATER & WASTEWATER ACCOUNT # *
BANK NAME *
BANK ROUTING # *
BANK ACCOUNT # *
CHOOSE WHICH ONE APPLIES: *
ARE YOU CURRENTLY ENROLLED IN AUTO PAY AND ARE CHANGING BANKS OR ACCOUNT NUMBERS?: *
IF YES, DO  YOU WANT US TO DRAFT YOUR CURRENT BANK ACCOUNT ON FILE THIS MONTH (IF NOT ALREADY DRAFTED)? *
ADDITIONAL COMMENTS
I authorize the City of Greensburg Municipal Water & Wastewater (GMWW) to draw monthly bank drafts on my bank account shown above for the payment of my monthly water, wastewater and sanitation bill. I understand that I can discontinue my participation in APS by notifying GMWW in writing prior to the next billing date. Also, both GMWW and the bank may terminate this agreement at any time. I understand that the GMWW reserves the right to limit participation in APS to customers whose accounts are in good standing. I understand that if funds are unavailable at the time of transfer,  the amount of my current bill will be charged back to my account,  along with a $27.50 NSF charge. Additionally, I understand that I will immediately be terminated from this program. *
SIGNATURE *
EMAIL ADDRESS *
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