Topsail Beach Bank Draft Application
Authorization Agreement for Electronic Transfer of Funds via Bank Draft Debits. Instructions: Please complete this entire form and click submit. An image or pdf of a voided check from your account will be required before submitting the form. This agreement may be revised or terminated at any time by written notification or by resubmitting the form to the Town of Topsail Beach Water and Trash/Recyling Services.
Check appropriate box:
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New Enrollment
Change Bank Account Info
Discontinue
Your Information
Name
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First Name
Last Name
Suffix
Water Account Number
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Your Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
example@example.com
Checking Account ACH Debit Authorization
Routing Code
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Account Number
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Scanned/Photo of Voided Check (or documentation from your bank with the above information)
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Browse Files
Drag and drop files here
Choose a file
Cancel
of
ACH Debit Authorization
I acknowledge that Bank Draft will take place on or about the 23rd of each billing month.
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Yes
I acknowledge that if my Bank Draft is returned I will be charged a $25.00 returned check fee.
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Yes
I hereby authorize the Town of Topsail Beach to automatically withdraw my water and trash/recycling payment from my acount by initiating Bank Draft debit transactions per the amount, frequency, and account information stated on this form.
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Yes
Signature
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Submit
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