Automatic Bank Draft
Enrollment Form
(City of Jennings, LA Water Dept.)

I (we) authorize the City of Jennings and the financial institution shown below to automatically debit
the bank account shown below for payment of all bills issued.  I understand that it is my responsibility
to notify the City of Jennings, in writing, if I change banks or account numbers.  This authorization will
be in effect until either party gives written notice to the other of termination.  I understand my notice of
termination must be received in time to have reasonable opportunity to act.

Customer:                                                                       City of Jennings Acct. #:                                    

Daytime Phone:                                                              Social Security #:                                                

Account Type:  Checking                 Savings                 Bank Acct. #:                                                     

Bank Name:                                                                    Routing #:                                                          

Customer's Mailing Address:                                                                                                                    

City:                                                                                  State:                       Zip:                                  

Signature:                                                                                 Date Signed:                                            

Mail completed enrollment form to:

Attn:  Customer Service
City of Jennings Water Dept.
PO Box 1249
Jennings, LA  70546                           Questions?  Call:  337-821-5502

IMPORTANT:  Attaching a voided check is strongly recommended.