ACH Form ACH-Form Apply for Automatic Clearing House billing here. Name(Required) First Last Email(Required) Phone Number(Required)Service Location(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where is service needed?Billing Address(Required) Use my Service Location Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code WDTSA Account Number(Required) Name on Checking/Savings Acount(Required) I WISH TO HAVE MY PAMENTS WITHDRAWN AUTOMATICALLY FROM THE FOLLOWING ACCOUNT(Required) CHECKINGS ACCOUNT (PLEASE UPLOAD A VOIDED CHECK) SAVINGS ACCOUNT (OBTAIN THE FOLLOWING FROM BANK) Customer Account Number(Required) Bank Routing & Transit Number(Required) Upload a Voided Check(Required)Max. file size: 4 MB.Accepted File Types: JPG, GIF, PNG, PDFConsent(Required) AUTHORIZATION AGREEMENT FOR AUTOMATED CLEARING HOUSEI hereby authorize the financial institution I have named on this application to charge the account I have specified for payment on my WDTSA sewer usage bill. I agree that such charge to my account shall be the same as if I had signed a check to pay my bill. I have the right to stop payment of a charge by notifying WDTSA within 15 (fifteen) days of the due date of my bill. If I stop payment 2 (two) times in one year, I will be excluded from this plan. In addition, I understand that both the financial institution and WDTSA reserve the right to terminate this payment plan and/or my participation therein. At any time I may elect to discontinue my enrollment in this plan. Today's Date(Required) MM slash DD slash YYYY CAPTCHA