Authorization for Automatic Payment

You will receive a statement as usual showing payments received and current charges. However, you won't need to write a check, pay for a stamp and mail your payment to us. Instead, your payment will be automatically deducted on the due date from your checking or savings account.

By completing and submitting this form you authorize West Central Sanitation to initiate debit entries to my checking or savings account. This will remain in force until written notice of termination is received in such time and manner to afford a reasonable opportunity to act on it.

Customer Information

First Name *

Last Name *

WCS Account # *

Street Address *

City *

State *

Zip Code *

Bank Information

Bank Name

Bank Address

Bank Routing Number

Bank Account Number

Checking or Savings

Checking

Savings

Credit Card Information

Name on Card

Please enter the name as it appears on the credit card.

Credit Card Number

Please enter your credit card number

Expiration Date

Please enter the expiration date in the format (MM/YYYY) ie 02/2015

Automatic Payment Terms & Conditions

Residential and Commercial customers are eligible for West Central Sanitation Automatic Payment Plan ("APP") if the following requirements are met:

You must either have a current/valid U.S. bank account at a financial institution where the payment will be withdrawn or a valid credit card that the payment will be charged to.

Your Commitment to Us

It is your responsibility to:

Ensure there are sufficient funds available in your checking or savings account to meet each withdrawal on the due date. If there are insufficient funds in your account, your financial institution and West Central Sanitation may charge you a fee and/or interest. You are solely responsible for paying any fee and/or interest charged by your financial institution or West Central Sanitation. Check your account statement to verify that the amounts debited from your account are correct.

Advise us if the payment account is transferred or closed, or if the account details change no later than three (3) business days before the debit date.

Arrange an alternate payment method if you cancel the scheduled withdrawal.

Payment Obligations

On your due date, we will deduct your APP payment from the payment account you designate. Your billing statement will indicate that it is being paid through the APP when this service is activated. In the event that West Central Sanitation makes a billing adjustment to the account, West Central Sanitation will cancel the withdrawal and establish a new withdrawal for the amount and due date as indicated on the revised bill.

If two requests are returned for insufficient funds, you may be excluded from the plan. If you need to update your checking or saving account information, you can do so online through MyAccount. If the transaction is refused by your financial institution for any reason, including insufficient funds, closed account, or unauthorized account, West Central Sanitation will not be able to process your payment. Your West Central Sanitation account may be subject to additional charges if your payment is rejected, reversed or refused by your financial institution.

Cancellation

To cancel an APP withdrawal, you will need to notify West Central Sanitation at least three (3) business days before the transaction is scheduled to occur.

Termination

Participation in West Central Sanitation's APP is completely optional. We reserve the right to discontinue accepting APP payments at any time, for any reason without prior notice. We may send notification of termination of APP anytime after the termination is effective. We also may temporarily discontinue accepting APP payments, within our sole discretion. Termination does not affect your rights and obligations for APP payments prior to termination.

These Terms and Conditions do not supercede, modify or in any way mitigate your obligation to be bound by and comply with the West Central Sanitation MyAccount Terms and Conditions.

I HAVE READ AND UNDERSTAND THE FOREGOING AGREEMENT AND AGREE TO BE BOUND BY ALL ITS TERMS AND CONDITIONS.

I Agree