AUTHORIZATION: I hereby authorize MSWD to deduct funds from my account at the financial institution listed below to pay my MSWD bills. I understand that I can stop these automatic payments if I notify MSWD in writing. I also understand that MSWD may stop participation in this service if necessary.

Name:
MSWD Account Number:
Financial Institution:
Bank Account Number:
Address of Service:

After your application is processed, your MSWD bills will state the date on which the amount due will be deducted from your bank account. If you have any questions regarding a bill, or feel corrections need to be made, don't worry - just contact us before the deduction date to resolve any problems before the payment is withdrawn.

IMPORTANT: Auto-debit service may take up to 2 billings to take effect.
When service is activated, your bill will indicate "DO NOT PAY."

INSUFFICIENT FUNDS POLICY: Auto-debit may be discontinued if a customer account has Insufficient funds on two seperate occasions.
Insufficient funds are subject to penalties.

Authorized Signature:
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