Artesia Start Water Service Request

Name *

First

Last

Service Location *

Address Line 1

Address Line 2

City

State

Zip Code

Billing Address (if different from service location)

Email *

Home and Cell Phone Number

SSN *

Password

Confirm Password

DL # *

State *

Please identify the property type

A one-time deposit is required before services can be connected. Utility bills are posted on or before the 8th of each month. Payment is due by the 28th of each month.

Start Date

(if renting use move-in date)

Sign up for Bank Draft? *

Yes
No

Please complete the information below with your account holder information. *

First

Last

Elm Ridge Water Control Improvement District is hereby authorized to draft my bank account on the due date of each month for my monthly water utility bill. I authorize my financial institution indicated below to debit such amounts from my bank account. I understand that my account will be paid by draft until such time as I provide written notification to Elm Ridge WCID to cancel this authorization.

Checking / Savings Account *

Checking
Savings

Please note that you will continue to receive a monthly statement. The statement will show your current bill with “DRAFT” printed under the amount due.

Bank Name *

Bank City and State *

Bank Routing Number *

Account Number *

Authorizes Elm Ridge WCID to draft my bank account as indicated below on the due date of each month (the 28th) for payment of my water utility bill.

Upload Voided Check *

Click or drag files to this area to upload. You can upload up to 2 files.

Upload a picture of a voided check to allow confirmation of the account and routing numbers for bank drafting. This will reduce the odds of a returned ACH transaction due to typing errors.

Signature *

First

Last

Today's Date *

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Elm Ridge WCID in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Elm Ridge WCID may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned NSF which will be applied to my water utility account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

Artesia Start Water Service Request

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