Please Print Out and return to: Revenue Finance, City of Charlotte, 600 East Fourth St., Charlotte, NC 28202

The City of Charlotte is authorized to debit my_____checking_____savings account number____________________at the_____________________branch of____________________located at____________________for monthly water, sanitary sewer and stormwater changes.  I understand that this authorization will be in effect until the City of Charlotte and my financial institution are notified in writing that I no longer desire this service, allowing them reasonable time to act on my notification.  I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my account.

I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged.  If an erroneous debit entry is charged against my account, I have the right to have the amount of the entry credited to my account by my financial institution, if, within 15 calendar days following the date on which I was sent a statement of account or a written notice of such an entry or 45 days after posting, whichever occurs first, I give my financial institution a written notice identifying the entry, stating that is in error and requesting credit back to my account.

THIS AUTHORIZATION IS NON-NEGOTIABLE AND NON-TRANSFERABLE

Customer Name___________________________________

Service Bill Account Number_________________________

Street Address____________________________________

City_____________________________________________

State____________________________________________

Zip______________________________________________

Phone (Day)______________________________________

Phone (Night)_____________________________________

Authorized Signature_______________________________

Authorized Signature_______________________________

BE SURE TO ATTACH YOUR "VOID" CHECK OR SAVINGS ACCOUNT WITHDRAWAL SLIP TO THIS AUTHORIZATION FORM