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2. Name*
3. Address of Service*
5. City / State / Zip*
6. Account Number*
8. Mailing Address (If Different From Above)
9. City / State / Zip (If Different From Above)
11. Phone*
12. Email Address*
14. I hereby authorize Uwchlan Township to debit funds from the account at the Financial Institution designated below. This authorization will remain in effect until I initiate the required stop action in such time and in such manner as to allow Uwchlan Township a reasonable opportunity to act upon it. I agree to notify Uwchlan Township if I wish to change the designated Financial Institution or account from which the funds are to be debited from 30 days prior to the effective date of such change. I understand that failure to do so may delay Uwchlan Township’s receipt of funds.
16. Signature*
17. Date*
    Date
19. Any questions regarding direct debit may be referred to 610-363-9450.
21. Name & Address of Financial Institution*
23. Routing Number*
24. Account Number*
25. Account*

    1. Checking
    2. Savings
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

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