Automatic Bank Drafting Enrollment

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Please correct the fields below:

Please correct the field(s) marked in red below:

To sign up for emergency notifications for things such as water main breaks, water quality changes, water pressure issues, etc. please visit pearlandtx.gov/alerts for more information.

1

Customer Information

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Customer Information

Last Name

First Name

Account Number

Service Address

Phone Numberext.

Email Address

2

Account Holder Information

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Account Holder Information

Name as on Account

Name of Bank

Routing Number

Account Number

Customer Agreement Terms & Conditions

3

I understand that by enrolling in this program the total amount due on my account will be drafted monthly on my due date and can take up to 30 dates to go into effect.

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Initials

4

I understand that to suspend or terminate this program, I am required to submit a request in writing 10 business days before my due date or the payment will have the possibility of processing on my due date.

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Initials

5

I understand that if my bank draft is declined for any reason, I will be charged a $35 NSF fee and my account will be subject to penalties and/or disconnection.

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Initials

6

I understand that in the event my bank declines the transaction for any reason, I may be required to provide a voided check to confirm the accuracy of the banking information initially submitted.

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Initials

7

Today's Date

*

Today's Date

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Email Address