I (we) authorize SEWUD to initate debit entries to my (our) checking account for payment. The financial institution named below is authorized to charge these bills to my (our) account.

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SEWUD account name(s)

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SEWUD account numbers(s)

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Address

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City_________________State _____ Zip

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Bank Name

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Bank Account Number

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Bank Address

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City_________________State _____ Zip

Both SEWUD and my financial institution have the right to cancel my use of the Pay-By-Bank plan. I will write to SEWUD if I decide to cancel my use of the PAY-BY-BANK plan.

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Signature as shown on bank account

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Daytime phone number------Today's Date

SEWUD reserves the right to terminate this plan in the event of "insufficient funds" or refusal to pay for any other reason. A $20 charge will apply for handling any refusals of payment as well as any charges the financial institution may incur.