Auto Pay Authorization Form

Please complete this form to authorize Murphys Sanitary District to set your account up on monthly auto pay. You can choose any day of the month from the 1st - 25th for payment withdrawal. By completing this form, you authorize a one time set up fee of $.50. Processing times may vary from 3-5 days. MSD will charge $35 for returned payments.

Customer # (required)

Date (required)

Service Address (required)

Email (required)

Type of Authorization (required)

Last Name (required)

First Name (required)

Mailing Address (required)

City (required)

State (required)

Zip (required)

Date of Monthly Payment (1st-25th) (required)

Regular Monthly Payment Amount (required)

Please debit payments from my (required)

Routing Number: (required)

Account Number: (required)

By typing your full name below, you authorize the District to process debit transactions to your account. You also understand that this authority will remain in effect until you provide reasonable notification to terminate the authorization.

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