Auto Pay Authorization Form

Please complete this form to authorize Murphys Sanitary District to set your account up on auto pay. You can choose any day of the month from the 1st - 25th. By completing this form, you authorize a one time set up fee of $.50.

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)

1st Payment Amount (Includes any balance due and set up fee) (required)

Regular Monthly Payment (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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