ACH is HERE!!!!!! Great opportunity to simplify your life.

Take advantage of Raytown Water Company’s automatic payment plan.  The stress free way to
make your monthly water bill payment from your bank account on the due date of your account each
month.  

By signing up, you will have no more check writing, no more postage cost, no more forgotten
payments, no more incurring late fees and penalties, thus ensuring a good payment record with
Raytown Water Company.  All you have to do is complete the enclosed authorization from and mail it,
along with a VOIDED CHECK or SAVINGS DEPOSIT slip to us.  When we receive your authorization,
we will process your request and notify you of your first draft date.  Please continue to make your
monthly water payment in the usual manner until you receive the draft notification.

Please put your account number and service address on the attached from prior to mailing.  You
may send your completed application and VOIDED CHECK via fax 816-356-0331.

If you have any questions, please call our office, Monday – Friday, 7AM – 4PM.
816-356-0333.


Raytown Water Company
RWC - Application for Automatic Payment (ACH)


Account Number: ________________     Service Address: ____________________________

I (we) hereby authorize Raytown Water Company to draft my (our) account referenced on the attached voided check or savings
deposit slip on the DUE DATE  of the month and for the amount stated on the monthly billing statement, as well as any additional
amount designated below.  I (We) also understand and agree to the following:

I (We) will continue making payments to Raytown Water Company until notification is received of the first month and day my draft
will be effective.

This authorization form must be COMPLETED, SIGNED AND RETURNED with a BLANK and VOIDED check or savings deposit slip
to:


A 30 (THIRTY) DAY WRITTEN NOTIFICATION IS REQUIRED IF I (WE) DECIDE TO DISCONTINUE DRAFTING OR CHANGE THE
ACCOUNT FROM WHICH PAYMENTS ARE TO BE DRAFTED.

I (We) understand that the monthly payment amount may change and I (we) will be notified of the amount in advance and agree
that Raytown Water Company may continue to draft my (our) account for the new amount.

I (We) may be terminated from this program if the draft is returned because my account has insufficient a funds or is otherwise
dishonored.  I (We) will promptly send Raytown Water Company the payment amount plus late charges and any penalties
assessed under my account.

In addition to my total monthly bill amount, I (we) want an additional $__________ drafted from my (our) account each month to
be applied to my water account.  I (We) understand that if my (our) payment changes, this additional payment amount will not
change and will continue to be drafted unless I (we) provide Raytown Water Company with 30 days written notification

                  
Bank Name:        __________________________________   Current Date: ______________

Name 1 on Water Account (Print): ___________________________________

Name 1 on Water Account (Signature): _______________________________

Name 2 on Water Account (Print): ___________________________________

Name 2 on Water Account (Signature):_______________________________    
               
Bank Telephone Number  :__________________________
                     
Bank Routing Number   :____________________________

Bank Account Number  :_____________________________

Daytime Telephone Number: __________________________
                     

DRAFT (Circle One)                SAVINGS           or        CHECKING
RWC ACH