AUTOMATIC PAYMENT EXPRESS Authorization Card
I authorize Vera Water and Power (Vera) and the financial institution named below to withdraw variable ACH (Automated Clearing House) entries from my account. This authority will remain in effect until I give a 30-day written notice to terminate this authorization . I also understand that Vera and/or my financial institution may stop my participation in this service, if necessary.
Your Name: (As it appears on bank records) __________________________________ Office Use Only ___________________________
Your Vera Account No. ___________________________________________________
Name on Vera Account ___________________________________________________
Street Address where you receive Vera service _______________________________
Bank account number (Attach your voided blank check) _________________________________________________________
Bank routing number _____________________________________________________________________________________
Daytime phone number ________________________________ Date: ___________________________________________
Name ( Please Print) _________________________________ Name (Please print) _________________________________
Signature _________________________________________ Second Signature (if require) ___________________________