I (we) hereby authorize City of Weatherford to initiate debit entries to my(our) account indicated below at the Depository named below, and further authorize the Depository to debit the same.

Bank Name *

Name on Bank Account*

Bank Routing Number *

Bank Account Number *

First Draft will have to pre-note the bank, please allow one full billing cycle for draft to go into effect.

This authorization is to remain in full force and effect until the City has received written notification from me (us) of its termination in such time and in such manner as to afford the City and Depository a reasonable opportunity to act on it.

Authorization Provided by:*

City of Weatherford Account Number *

Email Address