AUTHORIZATION FOR AUTOMATIC PAYMENT …

15205 41st Ave SE, Bothell, WA 98012-6114 - Box 13888, Mill Creek, WA 98082-1888 Telephone (425) 337-3647 Facsimile (425) 337-4399 AUTHORIZATION FOR AUTOMATIC PAYMENT ( autopay ) Date: Service Address: Customer Name: SLWSD Account Number: Email Address: Telephone Number: I authorize Silver Lake Water and Sewer District to automatically withdraw from my account, as identified below and with the voided blank check copy attached to this form, for the amount due on my next bi-monthly or monthly utility bill. I also authorize the below named Financial Institution to accept Preauthorized Electronic Fund Transfers initiated by Silver Lake Water and Sewer District on a recurring basis.

15205 41st Ave SE, Bothell, WA 98012-6114 - P.O. Box 13888, Mill Creek, WA 98082-1888 Telephone (425) 337-3647 Facsimile (425) 337-4399 AUTHORIZATION FOR AUTOMATIC PAYMENT (AUTOPAY)

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