Authorization Agreement for Automated Payments

AUTHORIZATION AGREEMENT FOR AUTOMATED PAYMENTS


I, (we), hereby authorize the Lost Creek Municipal Utility District to initiate debit entries to my (our) checking or savings account indicated below and the Depository named below to debit same to such account. A VOIDED CHECK IS ENCLOSED.

The authority is to remain in full force and effect until the Lost Creek Municipal Utility District and Depository has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the Lost Creek Municipal Utility District and Depository a reasonable opportunity to act upon it.

Name:_________________________________

Address:_______________________________

Utility Bill Acct#:____________________

Depository Name (your bank):_____________________

City:____________________ State:________ Zip:__________

Customer Signature(s)__________________________________

Date_____________________

updated: Friday, February 25, 2011