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  • 315 S Hudson St, Buckner, MO 64016
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Automatic Draft / Water Bill Payment Authorization Form

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  • Automatic Draft / Water Bill Payment Authorization Form

Automatic Draft / Water Bill Payment Authorization Form

Your Personal Information
Your Name as it appears on your Water Bill:
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Daytime Phone Number:
Service Address
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City
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State
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Zip
*
Email Address
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Confirm Email (retype)
*
Financial Institution Account Information
Account Number as shown on your Water Bill:
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Financial Institution Name
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Financial Institution Address
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City
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State
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Zip
*
Your Banking ROUTING Number
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Retype Banking ROUTING Number
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Your Banking ACCOUNT Number
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Retype Banking ACCOUNT Number
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Type of Account?
CHECKINGSAVINGS*
Example on where to find Routing and Account Numbers
Upload an image of a voided check or deposit slip* allowed file types: image (jpg, png, gif), PDF or Word (doc,docx)
*
Consent and Authorization
I hereby request and authorize the financial institution named to pay my monthly Buckner Water Utility 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 named reserve the right to terminate the payment plan or my participation therein.

Please draw your signature, and then below that type your full name and verify the current date to state agreement to the above statement and information:
Use your finger or mouse to sign in the box below:
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Signed - type full name as signed above
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Date Signed

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