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Set Up Recurring Payments

Angelina Water Supply Corporation
5978 FM 841
Lufkin, TX 75901
Phone: (936) 824-2865
Fax: (936) 824-2965

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To activate your Monthly Recurring Billing Option please complete the required payment details.

Payment Type

Electronic Check (from your checking or savings account)

Contact Information

Name of Bank
ABA/Routing #		(First number at bottom of check)
Checking Account Number		(Second number at bottom of check)
Account Name		(From your bill)
Utility Account No.		(From your bill)
Phone No.
Email Address
	Check this box to donate $1 every month to the Volunteer Fire Department. One dollar will be added to your bill every month.

Notice

I (we) hereby authorize Angelina Water Supply Corporation ("Angelina") to automatically withdraw from my Checking Account or Credit Card the amount the total amount due on my billing statement and to make deposits if necessary for error correction. I authorize the Financial Institution named above to accept such transactions initiated by Angelina. Deductions will be made on the first business day after the designated due date. I am aware of my right to stop a withdrawal by notifying Angelina. at any time up to three (3) business days before the withdrawal date. If an erroneous withdrawal occurs and I notify the Financial Institution of the error within 60 days of the issuance of my account statement, the institution must investigate and resolve the error within 45 days of notification. If the error is not resolved within the first 10 business days following receipt of my notification, my account shall be recredited for the amount in question until the investigation is completed. (Condensed for Regulation E, Electronic Fund Transfer Act for the consumer's protection. For more information, contact your Financial Institution.)

By sending in this request to activate your Monthly Recurring Billing you are agreeing to the above terms.

Approval

Full Name:

I Agree