CITY OF GREENSBURG MUNICIPAL WATER AND WASTEWATER
Automatic Payment System (APS)
Authorization Form
   

 

First Name: 

Last Name: 

Service Address: 

Mailing Address: 

State: 

Zip Code: 

Home Phone: 

Business Phone: 

Email Address: 

GMWW 
Acct Number: 

Bank Name: 

Bank  
Transfer #: 


(Check with your bank for this number)

Bank  
Acct Type: 


(Checking or Savings)

Bank  
Acct Number: 

 
 
 


Upon typing my name in the signature box below:
I authorize the City of Greensburg, Municipal Water & Wastewater (GMWW) to draw monthly bank drafts on my bank account shown above for the payment of my monthly water, wastewater & sanitation bill. I understand that I can discontinue my participation in APS by notifying GMWW in writing prior to the next billing date. Also, both the GMWW and the bank may terminate this agreement. I understand that the GMWW reserves the right to limit participation in APS to customers whose accounts are in good standing.

I understand that if funds are unavailable at the time of transfer, the amount of my current bill will be charged back to my account, along with a $27.50 NSF charge. Additionally, I understand that I will immediately be terminated from this program.

 

Electronic  
Signature: 

Date: 

 
 
 

Your draft will start the month following your application. When you receive your monthly bill, a notation of the BANK DRAFT DATE will be on the left bottom portion of your bill. If you have questions please phone our office at 812.663.5621.
Thank you for signing up for AutoPay.

 
  
 
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