Auto Draft Payment Option

Here at H2O4U, not only do we strive to improve the water quality in your home, we would also like to help make life a little easier by offering you our automatic payment option.

To get started, all that you would need to do is fill out this form and return it to us via fax, email or mail.

Please charge/debit my checking or savings account per the account statement/invoice balance on the 15th of each month. This authorization will remain in effect until cancelled by myself in writing.

Signature ________________________________________

Date ___________

Name (please print) ________________________________________

Bank Account #____________________________       checking    or     savings    (Circle one)

Bank Routing #_________________________

H2O4U Account #______________________

For those who like to earn points/miles with every dollar they spend, the automatic credit card debit will allow you to do this.

By having your payments automatically charged to your credit or debit card, you can save time, money, and the environment -- no more stamps and envelopes!

You would also have the ease of mind knowing that your payment will never be late.

***Please note: If you are already on automatic payments, do nothing, your status has not changed.

Thank you.

*** Questions? Please call our Billing Department at 800-383-1485.

AUTO DRAFT AUTHORIZATION

Please charge/debit my credit card per the account statement/invoice balance on the 15th of each month. This authorization will remain in effect until cancelled by myself in writing.

Signature ________________________________________

Date ___________

Name (please print) __________________________________________ _____

H2O4U Account number_____________________________

CREDIT/DEBIT CARD DRAFT:

Type of Account: Visa Master Card American Express

Name on Credit Card Account____________________________________



Credit Card #: _______________________

Exp. Date: ______________*VIN______________

*The verification code (v.code) for American Express appears on the front of the card and is 4 digits; for Visa/MasterCard it appears on the back of the card and is either the last 3 or 4 digits.

I understand that it is my responsibility to notify your company of expiration date changes.