AUTOMATIC BILL PAYMENT OPTION ENROLLMENT FORM (Please print this form, complete the information and deliver it to the MTMA Office) To initiate the automatic bill payment option, please complete the enrollment information below and deliver it via mail or drop-off to the MTMA office at 1700 Beaver Grade Rd., Suite 200, Moon Township, PA 15108. I/We hereby authorize Moon Township Municipal Authority to automatically debit my/our checking account (one account only) for the amount of my MTMA utility bill. This authorization will remain in full force and effect until notified by me in writing. My/Our participation in this program is subject to MTMA's approval. I understand that MTMA reserves the right, upon written notification, to terminate my participation or terminate the program at any time.
MTMA Account # ___________________________ Service Location ______________________________ Billed to Name _______________________________ Bill to Address ________________________________	Your Telephone # ___________________
Information for Draft Account: _______________________________ Print - Name on the Account _______________________________ Your Signature	_______________________________ Print Joint Name on Account _______________________________ Joint Account Holder Signature
Financial Institution Name: __________________________________ Checking - Account Number: ________________ (Please enclose a voided check)
Is the specified account: __________ Residential	__________ Business
ABA Routing #: ___________________________ (Please verify with your bank) Note: After receipt of your enrollment form, there will be some processing time required to implement the withdrawal process. When you receive your first bill with the words "Do Not Mail a Payment," you can assume that the bill amount will be withdrawn from your bank account.
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