UTILITIES

Name on Water Account *

First Name

Last Name

Terms & Conditions Agreement *

I hereby authorize the Village of Ruidoso Utility Billing to initiate withdrawals from my Designated Account at the financial institution named, for payment of the monthly service bills. The withdrawals are to be made on the due date of each monthly bill. I authorize my financial institution to charge such withdrawals to the Designated Account. I understand that the first draft on my Designated Account for payment of my service bill will occur on the due date of the first bill identified as an Automatic Payment Bill. Any bills prior to this automatic bill will not be debited from the Designated Account. I understand that both the Utility Billing Department and the financial institution reserve the right to terminate this plan and/or my participation therein. I also understand that the Village of Ruidoso’s ordinances and conditions for providing service shall remain in effect and applicable hereto, as filed in the Utility Billing Ordinance for the Village of Ruidoso.

I agree

Daytime Phone *

(###)

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Service Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Alternate Contact Phone

Country

(###)

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Account Type *

Checking

Savings

Bank Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment Agreement *

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Village of Ruidoso in writing of any changes in my Designated Account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account. I understand that because these are electronic transactions, these funds may be withdrawn from my Designated Account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the Village of Ruidoso will charge a $30.00 fee for the returned NSF payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

I agree