Bank Draft Form

Preauthorization Form

I (we) hereby authorize Northeast Knox Utility District and Automated Payment Systems, Inc. acting on behalf of Northeast Knox Utility District to initiate debit entries to such account by funds transfer for payment of my monthly utility bill.

This authority is to remain in full effect until I notify Northeast Knox Utility District that I wish to end this agreement and Northeast Knox Utility District has had reasonable time to act on it; or until Northeast Knox Utility District has sent me 10 days written notice that they will end this agreement.

I understand that Northeast Knox Utility District will continue to send me a bill and that there will be a minimum of 15 days after the date of billing to notify Northeast Knox Utility District of any error on the bill.

I further understand that in the event my account has insufficient funds to cover the monthly payment amount drafted, or my monthly draft rejects due to account closed status, bank ownership changes or account changes, a $25 fee will be assessed and debited from my account in addition to the monthly payment due. It is my duty to notify Northeast Knox Utility District 15 days prior to a scheduled debit of any changes made to my designated depository account, including but not limited to closed status, bank ownership changes and account changes.

I attest I am an authorized owner of the Depository Account listed below, and am exercising my powers as such.

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^{Authorized Signature}	^Date

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^{Depository Account to be Drafted}Please Attach a Voided Check

Sign Up Form for Free Automatic Draft Program

Northeast Knox Utility

Account Number:

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Name:

____________________________________

Billing Address:

____________________________________

City:

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State:

____________________________________

Zip Code:

____________________________________

Phone Number:

____________________________________

Voided Check Enclosed?

Yes q

Northeast knox Utility District must receive this form and voided check at least 15 days prior to your next bill date in order to draft your upcoming utility bill. Send this form with your current monthly payment, to be assured next month's bill will be drafted.

(To be Completed by Northeast Knox Utility District)

Cycle #:

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Date:

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