Direct Payment Enrollment Form

Name (as shown on utility bill)*

HBPW Account Number - 10 digits with no dashes*

Mailing Address

City/State/Zip*

Service Address

City/State/Zip (Service)

Daytime Telephone

Name of Bank or Financial Institution*

ABA/Routing Number*

Please re-enter your routing number*

Please Select One:

Account Number*

Please re-enter your account number.*

Email Address*

Re-enter Email Address*

I authorize HBPW to deduct my utility payment due from the checking or savings account listed above on the due date each month. I understand that I control my payments, and if at any time I decide to discontinue this service, I will provide written notification in such time and manner as to afford the HBPW and my depository a reasonable time to act on it. I also understand that all information provided will remain confidential.

Electronic Signature (Please Type Full Name)*

Date*

Please Confirm: