Billing Clerk completed
Date of BC completed:  	
Internal Use Only

Date Received  		                     Account #  	 Entered by:  	 
Date Entered: 	

AUTOMATIC BANK DRAFT AUTHORIZATION FORM

Please complete and return this form to St. Lucie West Services District (SLWSD)
at the address listed below. Provide a voided check or a direct ACH debit authorization letter from the bank.

Print Customer Name shown on St. Lucie West Services District Account Statement (Utility Account Holder) Utility Account Number
Service Address

Mailing address (if different from service address)

Restrictions
No international or starter checks are accepted at this time.
Bank draft will be canceled if a payment is returned three (3) times within a 12 month period for NSF’s. Any future payments must be submitted by a money order or credit card for a minimum of twelve (12) months. Customer may ask for a financial review after 12 months for approval to accept checks again.
Bank draft will be automatically canceled when the account is closed, frozen or the bank cannot locate the account.
Bank draft process cannot be applied to a final statement. Please submit payment by check, money order, or credit card.
All requests must include a voided check or direct ACH debit authorization letter.
The Utility Account Holder shall resume responsibility in selecting another method of payment at the time a bank draft cancellation is submitted for the checking account included on the enclosed voided check.
Authorization
I (We) hereby authorize SLWSD to automatically commence debit entries (charges) to my bank account (and for my bank to accept and post such debit entries) indicated above for the payment of all bills rendered by SLWSD to the service address above.
I (We) understand that SLWSD will continue to render a bill before my bank account is to be debited and that SLWSD may impose a fee in the event a debit entry is not paid by my bank.
This authorization is to remain in effect until SLWSD has received a completed “Cancellation of Automatic Bank Draft
Form”.
I (We) have the right to stop payment by notifying SLWSD in writing seven (7) days prior to the time the bank account has been debited.
Any erroneous or incorrect debit will be corrected upon notification to SLWSD. If corrections in the draft(s) are necessary, it may involve a credit or debit to my utility service account.
I authorize payments each month to be retrieved twenty (20) days after the statement date.

Checking Account Holder Name(s):		
PRINT		
Checking Account Holder Signature(s):    		Date:   		
(2nd Signature if applicable)	 		Date:   		
Submit this completed form with voided check by: MAIL, FAX or EMAIL to customerservice@slwsd.org
St. Lucie West Services District

450 SW Utility Drive Port St. Lucie, FL 34986

Updated 8-18-20

Telephone: (772)340-0220	Facsimile: (772)871-5771	Website: www.slwsd.org