RRWA Water E-Pay * Unfortunately, due to the additional hardware and software programming costs associated with providing these services, RRWA is charging a $2.50 administration fee per payment transaction. However, due to the significant cost savings in bank charges when individuals choose ACH transactions (paying by checking or savings account), the $2.50 administrative fee will be waived for those selecting ACH instead of credit cards. Additionally, credit cards will be limited to the following: Visa, Master Card, Discover and American Express. (please attach voided check or deposit slip) or Credit Card Payment Regular mail ___ Email ___ Send Overdue Notices by: Account#: _______________ Signature: __________________________________ Email Address: _____________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Credit Card Expiration Date(Mo./Yr.): __________ Credit Card Type (MstrCd/Visa/etc.): _____________________________ Credit Card#: _____________________________ Telephone: (Day)________________(Evening)_______________ City, State, Zip: _____________________________ Address: _____________________________ If you have a problem printing this form, or have other questions, please call customer service at (800) 233-8849. Centerville, IA 52544-8307 16166 Hwy J29 Attn: Internet Bill Payment Application 3. Mail the completed form to us at the following address. Application for Internet Bill Payment 1. Use the print button on your web browser to print this form. 2. Complete the form. Rathbun Regional Water Assoc. Instructions Print Name: _____________________________ Account#(s) for Internet Billing: Credit card name & billing address must match above. ABA Routing#: _______________ Method of Payment * Checking/Savings (Circle One) Customer Information Customer Accounts This authorization is to remain in full force and effect until RRWA has received written notification of its termination in such time and in such manner as to afford RRWA and depository a reasonable opportunity to act on it. In no event shall termination be effective with respect to entries originated prior to receipt of notice of termination. Date: _______________ Bank Acct Withdrawal