Customer Name: * Water Account Number * Service Address * Email Phone Number * Statement Preference Email Printed If E Statements are selected must provide email address Bank Name * Account Number * Routing Number * Signature * Important Notice: I grant Pottsville Water & Sewer to draft my bank account listed above for payment amounts due for my water bill on the 15th of every month. The fee for this service is 25 cents per month, this authorization is to remain in effect until revoked by me in writing. Non sufficient fee for returned ACH are $35.00. Leave this field blank
