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Pre-Authorized Payment Application
All fields are required

I hereby request and authorize the Brunswick and Topsham Water District to make deductions from my bank account 10 days or more after the billing date. I agree that if a payment is rejected, that I am responsible for any bank charges that may occur and alternate payment may be requested. This authority is to remain in full force and effect until the Brunswick and Topsham Water District has received written notice from me of its termination in such time and in such manner as to afford the Brunswick and Topsham Water District a reasonable opportunity to act on it. I acknowledge that origination of EFT transactions to my account must comply with provisions of U.S. law. This information will be used by the Brunswick and Topsham Water District only for the processing of water payment and will be kept strictly confidential.

PLEASE NOTE: If you currently have an outstanding bill, please mail in your payment. Your EFT enrollment will take effect when your invoices state "Do Not Send Payment".
Name on Bill:
Account Number :
Phone Number:
Service Address:
City, State, Zip
Mailing Address:

City, State, Zip , ,
Name of Financial Institution
Checking Account Number
ABA/Routing Number (9 Digits)
Maximum Deducted Per Bill