Internal Use Only
•	Account #: 	
•	Entered by Initials/Date: 	
•	CSR reviewed Auto Draft Form info. on account initials/date: 	
•	CSR placed Auto Draft form in BC bin Initials/Date: 	
•	BC/Designee added account to auto draft file Initials/Date: 	

AUTOMATIC BANK DRAFT AUTHORIZATION FORM

Please complete this form with a voided check or (ACH debit authorization letter from your bank) and return by mail, email or drop off at:
St. Lucie West Services District (SLWSD) 450 SW Utility Dr., Port St Lucie, FL 34986
Or email to customerservice@slwsd.org or fax to (772) 871-5771 Complete the following information (PLEASE PRINT) Account Holder Name (shown on SLWSD statement):

Utility Account Number (shown on SLWSD statement):
Service Address (Property Address):

Main Telephone Number:

Restrictions
1.	No international checks are accepted.
2.	Bank draft will be canceled if payment is returned three (3) times within a 12-month period for NSF’s. Any future payments must be submitted by 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.
3.	Bank draft will be automatically canceled when the account is closed, frozen or changed for unknown reasons.
4.	All requests must include a voided check or direct ACH debit authorization letter.
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” from you the utility account holder, bank account holder, or other authorized person. Restrictions (2 or 3) above will affect the bank drafts if they occur.
•	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 Accountholder Name(s):		
	PRINT NAME	
Checking Accountholder Signature(s):		Date:		
2nd Signature (if applicable):		Date: