The Municipal Authority of the Borough of Derry

Application for Automatic bill payment

Name:  _______________________________________________ Date:___________

Address: ______________________________________________

Phone Number: _________________________________________

Bank Name: ____________________________________________

Bank routing Number:_____________________________________

Bank account Number: ____________________________________

Water account Number: ___________________________________

Signature: ___________________________________________

Deduct from:            Checking     or        Savings

Payment will be deducted from your designated account on the 15^th of the month that the bill is due.

Copy of Check:

* Please Print and return to the Main office at: 620 N. Chestnut St.  Derry, PA 15627