Logo
Bank Draft Authorization Form
 
This form authorizes Mallory Valley Utility District to draft your checking account for payment.
A billing statement will be mailed to you around the tenth (10th) of each month.
Payment by bank draft will begin on the next Full Billing Cycle.
The amount is then drafted from your account on the first (1st) of the following month.

1. Please complete this form and attach a voided check from the account to be drafted.
2. If the account is a joint account, both parties must sign the bank draft authorization.
3. Payment of your bill by bank draft will begin the next billing cycle.
4. If you have any questions, please call the District office at 615-628-0237.
5. You can email the form and voided check to [email protected]
* indicates required field.
*  
 
*  
 
 
*  
*  
*  
*  

I (we) hereby authorize Mallory Valley Utility District to initiate debit entries to my (our) checking account indicated below and the bank named below, hereinafter called DEPOSITORY, to debit the same to such account.
*  
*  
*  

This authority is to remain in full force and effect until Mallory Valley Utility District and DEPOSITORY have each received notification from me (or either of us) of its termination in such time and in such manner as to afford Mallory Valley Utility District and DEPOSITORY a reasonable opportunity to act upon it. I (we) will receive prior written notice of the amount to be debited to my (our) account, which will allow me (or either of us) to stop payment of the debit entry by notifying the DEPOSITORY at least three days prior to the date the account is to be charged. I (we) will send written notice of an erroneous charge to the account to the DEPOSITORY within 15 days of the issuance of the account statement or 45 days after the account was charged, whichever occurs first.
*  
*  
Upload Voided Check
Max Size: 5MB. Please attach a voided check from the account to be drafted.
*
*



Municipal Forms - A Powerful document mangement system for Government