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Automatic Water Bill Payment Plan Authorization Form
(Print form and mail to: City of Buckner Water Department, P.O. Box 377, Buckner, MO 64016)

Your name as it appears on the bill:
Daytime Phone Number:
Service Address:

Your Account Number as shown on the Bill:
Financial Institution & Address:
Your Financial Institution Routing Number:
Your Financial Institution Account Number:

My Account is: Checking Savings (Check One) 

I hereby request and authorize the financial institution names to pay my monthly Buckner Water Department bill by charging each payment to the account specified by me. I agree that each payment shall be the same as if it were a check or withdrawal personally signed and authorized by me. This authority is to remain in effect until revoked by me in writing, and it is my responsibility to prevent rejected or returned payments. I understand that both the Buckner Water Department and the financial Institution names reserve the right to terminate the payment plan or my participation therein.

Signed: Dated:

Attach a voided Check or Savings Account slip here