City of West Melbourne

2240 Minton Road
West Melbourne, FL 32904
Phone: 321-727-7700
Fax: 321-768-2390

Tax ID Number: 59-604-4078

I hereby authorize the City of West Melbourne hereinafter called "Company", to initiate credit entries and if necessary, debit entries and adjustments for credit entries in error to my/our account (indicated below) and the financial institute named below, hereinafter called "Depository", to credit and/or debit to the same such account.

Please select one:*

Checking

Savings

Financial Institution:*

Branch*

City/State/Zip*

Transit/ABA No: (9 positions)*

Account Number:*

This authority is to remain in full force and effect until Company has received written notification from me (or either of us) of its termination in such time and in such manner as to afford said Company and the financial institution named above a reasonable opportunity to act on it.

Name:*

Water/Sewer Acct. No:*

Date:*

Signed: ________________________________

***Signed: ______________________________

*** TWO SIGNATURES REQUIRED FOR JOINT ACCOUNTS

A VOIDED OR CANCELLED CHECK MUST ACCOMPANY THIS REQUEST