AUTOMATIC BANK DRAFT AUTHORIZATION  
 

AUTHORIZATION FOR AUTOMATED BILL PAYMENT 

Return this form to The City of Mountain Home Water Department, 720 S. Hickory St, 
Mountain Home, AR 72653 

For additional information call: 870/425-5115 

Customer Water Account Number:________________________________________ 

Your Name ___________________________________________________________ 

Address ______________________________________________________________ 

City:_________________________________State:___________Zip_____________ 

Phone: (_______) ________________________________ 

  

  

Financial Institution: ___________________________________________________ 

City_________________________________State___________Zip______________ 

Check One:  Checking Account _____________ Savings Account ______________ 

Bank Routing Number_________________________________________________ 

Account Number______________________________________________________ 

  

IMPORTANT: Please return a voided check or deposit slip with this form to ensure 
accurate processing. 

  

I authorize the City Water Dept. to charge my checking/savings account the amount of 
my monthly water bill and to make that deduction payable to the City of Mountain 
Home Water Dept.. I agree to all the Terms and Conditions of Authorization. 


 Date:__________________Signature:____________________________________