Bank Draft Form

Applicant Name*

First

Last

Co Applicant Name

First

Last

Phone*

Co Applicant Phone

Service Address*

Street Address City Postal / Zip Code

Account Number*

authorize agreement

I authorize The City of Liberty Hill Utilities to deduct my bill payments from my bank account on the due date. I understand that if at anytime I decide to discontinue payment service, I will notify the City of Liberty Hill Utilities.

Insufficient Funds

I understand that if funds are insufficient to cover the amount, a charge will be added to the payment

Acknowledgement

I acknowledge the Bank Draft Program is a free service provided by the City of LH

Monthly Bank Draft From*

Checking Attach Voided CHK

Savings (Attach Withdrawal Slip)

Payment Type Upload

Signature*

First

Last

Word Verification

Date*