BANK DRAFT

Bank Draft Form
Utility Billing Department
418 W Henderson St.
P.O. Box 657
Cleburne, TX 76033
817-645-0919
Water Account Number*
Customer Name*
Service Address*
Email Address*
Home Phone #*
Other Phone #
Draft Option

New Bank DraftChange Bank DraftCancel Bank Draft
Bank Name*
Bank Address*
Bank Phone #
Bank Account Type*

Checking AccountSavings Account
ABA/Transit Number*
Account Number*
Check/Letter From Bank*

Please attach a check or letter from bank
Cancelof
Photo ID*

Please upload a copy of your drivers license or photo ID.
Cancelof
I (we) hereby authorize the City of Cleburne to debit my (our) checking / savings account each month for the amount of services billed on my utility account. I also authorize my Financial Institution identified below to debit these amounts from my account number listed below.

The authority is to remain in full force and effect until the City of Cleburne has received written notification from me (us) of its termination in such time and manner as to afford the City of Cleburne and the financial institution a reasonable opportunity to act upon it.

I(we) will notify the City of Cleburne Utility Billing Department of any changes to my bank account, or if I transfer water service to another address with the city limits.

The accounts will be drafted on the DUE DATE printed on your utility bill. If for any reason the draft is returned from my financial institution unpaid, my water account will be charged a $25.00 service fee.
Account Authorization Signature(s)

Clear
Date

MonthDayYear
Date
Should be Empty:

Bank Draft Form