Automatic Payment (ACH) Draft Authorization

Customer Name

Water Account Number

Customer Phone

Account Type
CheckingSavings

Voided Check Image
Attach a scan or photo of a voided check. For savings accounts, attach a scan or photo of a pre-printed deposit slip.

Non-Discrimination Statement
The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.

Ethnicity(optional)

—Please choose an option—Hispanic or Latino DescentNot of Hispanic or Latino DescentI prefer not to disclose

Race(optional)

—Please choose an option—WhiteAsianBlack or African-AmericanAmerican Indian/Alaska NativeNative Hawaiian or Other Pacific IslanderI prefer not to disclose

To cancel draft authorization, you must give 30 days notice (type your initials):

If you agree to authorize the City of Floresville to withdraw from your account in order to pay your monthly water bill, sign this document electronically by typing your full name:

...and today’s date:

Please click Submit button one time only. Transmission may take up to ten seconds.