2. 

3. Public Services Department 

   Authorization Agreement For Automatic Drafts

5. Yes, I want the convenience of having my utility bill automatically drafted from my checking account. 

7. Customer Name:
9. Customer's Utility Account Number:
11. Service Address:
13. Bank Transit/Routing Number:
15. Checking Account Number:

17. By electronically signing below, I authorize funds to be withdrawn from the checking account provided above. This authorization is to remain effective until the Town of Kill Devil Hills has received notification from me (account holder) requesting termination of draft. I will provide this information in such time and manner for the Town to reasonably act upon it.

19. Date:
    Date:
21. Name:
23. Electronic Signature (account holder):

25. Please Note: Application must be accompanied by a voided check (no deposit slips) from the account to be drafted. Application must be received in office at least ten days prior to due date in order to draft current bill.

27. Upload Voided Check*
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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