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Application for Automatic Water/Sewage Bill Payment via ACH

This form is used to set up automatic payments for water and sewage bills through the Ebensburg Borough using Automated Clearing House (ACH) transfers.

Key Details:

• Purpose: To allow automatic withdrawal of funds from a bank account to pay water/sewage bills.
• Required Information:
  • Service Address and Account Number (found on invoice)
  • Bank Routing Number (9 digits)
  • Bank Account Number (up to 17 digits)
• Validation: Must attach an original voided check to validate bank account details.

Instructions Summary:

1. Complete all sections of the form.
2. Attach a voided check in the designated area.
3. Sign and date the approval section to authorize withdrawals.
4. Mail or fax completed form to:

Ebensburg Borough
Attn: ACH Water Bill
300 West High Street
Ebensburg, PA 15931
Fax: 814-472-8789

Approval Section:

By signing, the applicant authorizes Ebensburg Borough to withdraw funds from the listed bank account for bill payments.

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Note: No document date is visible on this form.