Western Monmouth Utilities Authority

103 Pension Road, Manalapan, NJ 07726
732-446-9300

Authorization Agreement for Automatic Account Withdrawals For Quarterly Sewer Service Payments

WMUA Account #: *

Check One *
New Authorization
Cancellation of Automatic Account Withdrawals
Authorization to Change to Another Bank and/or Bank Account Number

I (we) hereby authorize WMUA to initiate automatic account withdrawals to my (our) checking/savings account indicated below at the bank named below. I (we) understand that this authorization will remain in effect until I(we) make a written request to WMUA to cancel the automatic account withdrawals and WMUA is afforded a reasonable opportunity to act on the cancellation request.

Bank Name *

9-Digit Routing (ABA) Number *
Please check to be certain you have posted 9 digits

Bank Account Number *

Bank Account Type (check one): *
Checking
Savings:

For checking account verification purposes, kindly attach a voided check with this application.

*

NOTE: If you are uncertain about how to attach documents online or do not have the equipment necessary to accomplish this task, you may print out your completed application, sign, and mail it along with your voided check to: WMUA, 103 Pension Road, Manalapan, NJ 07726

- Name(s) on Bank Account --If more than one, all must sign signature lines below-- *

Property Location:

Address, City, State, Zip Code * (Address Line 1)
(Address Line 2) (City)
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (State) (Zip Code)

Mailing Address (if different from above) * (Address Line 1)
(Address Line 2) (City)
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (State) (Zip Code)

E-mail Address

Confirm E-mail Address *

Daytime Telephone:

Alternate Telephone:

NOTE: Continue below to submit electronically, or print this application, hand sign it, and mail it along with your voided check to the address noted below.

Withdrawals will be made on the 25th of the month of billing. If a weekend or holiday occurs on that day, the withdrawal will occur on the next banking day. Please continue to submit your payments until notification appears on your bill that automatic account withdrawals are activated.

Automatic account withdrawals will only be initiated for accounts that are not delinquent. WMUA reserves the right to terminate your participation in this payment option at any time. All insufficient funds will incur a $20.00 fee.

WMUA will not disclose personal identifying information supplied by you on this form, as personal identifying information is deemed confidential pursuant to the Open Public Records Act, N.J.S.A. 47:1A-1 et seq.

Electronic Signature Disclosure and Consent Statement

You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon, check box, to enter text, or to perform a similar act/action, while using the Western Monmouth Utilities Website secure forms, for the purpose of accessing or making any transactions regarding any agreement, acknowledgment, consent, terms, disclosures or conditions, constitutes your signature, acceptance and agreement as if actually signed by you in writing.

You further acknowledge and agree that the taking of any such actions by you evidence your intent to sign any such agreement, acknowledgment, consent, terms, disclosures or conditions.

You also agree that no certification authority or other third party verification is necessary to the validity of your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract.

I, the applicant for/on this Authorization Agreement for Automatic Account Withdrawals, warrant the truthfulness of the information provided in this application. PRIMARY ACCOUNT HOLDER, please type or sign your Legal First and Last Name below *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree that I have typed my name and checked the box myself. *
Please check box to submit your electronic signature

I, the SECONDARY APPLICANT for/on this Authorization Agreement for Automatic Account Withdrawals, warrant the truthfulness of the information provided in this application. Additional Account Holder, please type or sign your Legal First and Last Name below . ***** If there is NO ADDITIONAL ACCOUNT HOLDER on this account you MUST type the word "None" in BOTH the First Name AND Last Name boxes below in order to proceed with the application******

I, the SECONDARY APPLICANT, understand that checking the electronic signature entry below constitutes a legal signature confirming that I acknowledge and agree that I have typed my name and selected an entry below myself. *****If there is NO ADDITIONAL ACCOUNT HOLDER on this account you MUST click the entry marked "None" in order to proceed with the application***** *
Please check here to submit your electronic signature
None - (no other account holder on this account)

Today's Date:

*******REMINDER:BE SURE TO REVIEW YOUR APPLICATION PRIOR TO SUBMITTING*******

PRINT BEFORE SUBMISSION

WMUA
103 Pension Road
Manalapan, NJ 07726

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