DEBIT AUTHORIZATION

I (we) hereby authorize North Baldwin Utilities (NBU) to initiate debit entries to my (our) account indicated below and the financial institution named below, hereinafter called Financial Institution, to debit the same to such account for (Application). I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Financial Institution Documentation Required

*Voided check or official statement, letter or card from financial institution clearly identifying routing number and account number accepted. NO deposit slips. Checking accounts only. No savings accounts accepted.

Authorization to remain in full force and effect until NBU has received written notification from me of its termination in such time and manner as to afford NBU and financial institution reasonable opportunity to act.

By checking this box, I am stating that the above information is true and accurate to the best of my knowledge. I will not hold NBU responsible for any errors I or my financial institution may make.

CUSTOMER SIGNATURE

PDF Version of Debit Authorization Form