Automatic Cash Tremsfr4CH/ppleuton Form  Name: Service. Address: Phone Number: Billing Address:  Sewer/Sanitation Account! Number: Name on Checking Account: Financial Institution: Iam owner oft this property.  Iam a tenant at this address.  Please write the owner's name and address on the back of this page.  Thank you.  Iwish to have my payments withdrawn automatically from the following account:  Checking Account (Enclose a voided check.)  Savings Account (Obtain the following from the bank)  Bank Routing & Transit Number: Bank. Account Number:  On the 20th ofe every month  Authorization Agreement for_Automatic Cash Transfer  Ihereby authorize the financial institution Ihave named on this application to charge the account. Ihave specified forj payment on my. Borough ofNesquehoning Sewer/Sanitation bill. Iagree that such charge to: my account shall be the same as: ifIhad signed a check to pay my bill. Ihave the right to stop payment ofa charge by notifying the Borough ofNesquehoning: within 15 (fifteen) days oft the due date oft my bill. IfIs stop payment 2 (two) times in one. year, Iwill be excluded from this plan. In addition, Iu understand that both the financial institution and/or the Borough ofNesquehoning: reserve the right to terminate this payment plan at any time. Also, Imay elect to discontinue my enrollment in this plan at any time. Ifat any time aj payment is returned for  insufficient funds, there will be a $35.00 fee assessed on your account.  Signature:  Date:  Return this signed form to: Borough ofNesquehoning, 114 W. Catawissa Street, Nesquehoning, PA 18240  Ifyou should have any questions, please call 570-669-9588.