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PERSONAL INFORMATION

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BANKING INFORMATION

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AUTHORIZATION INFORMATION

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I hereby authorize Utility Payment Center to initiate debit entries to my account from the entity named above (“institution”), and I authorize the institution to accept and to debit the amount of such entries to my account. Each debit shall be made each month in an amount equal to the monthly invoice upon processing.


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© Automated Utility Billing, LLC 2014 · P.O. Box 179 ∙ Little Elm, TX 75068