Printable Application Financial Institution Name: Routing Number: Bank Account Number: Account Type: Checking Savings Name: Address: Phone Number: WHUD Account Number: Date:(mm/dd/yyyy) I understand that White House Utility District will charge a $30.00 fee if the draft is not paid by my bank due to insufficient funds or my account is closed. After three failed attempts at processing the draft, White House Utility District retains the right to terminate participation in the draft program. This authorization will remain in effect until either party gives notice to the other of termination. I authorize White House Utility District to draft the amount of my monthly utility bill from the financial institution listed above. I understand that my account will be drafted on the due date indicated on each monthly statement.
