ACH Authorization

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Account Type

New ACH Authorization

Change ACH Authorization

Select "New" if you're setting up ACH for the first time, or "Change" if you're updating an existing ACH arrangement.

Customer Contact & Billing Information

Customer Name *

Phone Number *

Street Address *

City *

State *

ZIP Code *

Email *

LPRW Account Number *

Billing Information

Payment Schedule: LPRW will deduct your payment on the 15th of each month. If the 15th falls on a weekend or holiday, the withdrawal will occur on the following business day.

Banking Information

Account Type *

Checking

Savings

Business Account

Check this box if the checking or savings account is set up at your bank as a business or commercial account.

Bank Name *

Bank Address *

City *

State *

ZIP Code *

Bank Routing Number *

Usually found in the bottom left corner of your checks.

Bank Account Number *

Usually found in the bottom center/right of your checks.

Payment Authorization

Authorization Statement: I authorize Lincoln Pipestone Rural Water System to debit my account pursuant to the provisions set forth above. This authorization is to remain in full force and effect until LPRW receives written or verbal notification from me of my intent to terminate this Authorization at least four (4) days prior to the effective date of the transaction.

I understand that if I wish to have LPRW debit a bank account other than the one named above, I must sign a new Authorization and submit it to the office. I understand that if LPRW attempts to debit my account and there are insufficient funds in my account to allow such a debit, then I will be liable to pay an insufficient funds fee of $30.00. I understand that in such event, LPRW may cease any further attempts to debit my account as contemplated by this Authorization.

I represent that I am authorized to execute this Authorization and that the information set forth above is true and correct.

Your Signature *

Authorized Signature

Type your name to confirm your authorization, or sign the printed form.

Date *

Important: By submitting this form, you authorize LPRW to initiate debit entries to your financial institution. Standard banking rules and regulations will apply to all ACH transactions.

Required Documentation

Please attach a voided check or a savings deposit slip before submitting:

How to prepare a voided check:

Write "VOID" in large letters across the face of the check
Do NOT tear or damage the check
All account information must remain legible

Upload Voided Check or Deposit Slip *

Accepted formats: PDF, JPG, PNG (Max 5MB)

Questions? Contact LPRW directly:

Phone: (507) 368-4248 | Fax: (507) 368-4573 | Email: billing@lprw.com

Automated Clearing House (ACH) Authorization Agreement

Required Documentation

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