Bank Draft Authorization Form

Date you wish to start the bank draft: * 🛈 +

Blue Ridge Rural Water will draft the amount of the bill on the due date each month.

Name on the Blue Ridge Rural Water account

First and Last Name *

Email Address: *

Blue Ridge Rural Water Account Number *

Service Address: *

Please select the type of account: *

Checking

Savings

Please attach a scanned copy of the appropriate voided item for the type of account to be drafted. (A voided check for a checking account or a withdrawal slip for a savings account must be enclosed.) *

I authorize Blue Ridge Rural Water Co. Inc. to deduct my bill payments from my bank account. I will notify Blue Ridge Rural Water Co. Inc. if at any time I decide to discontinue this payment service.

Signature: *

clear

Date: * +

Please click submit and you will be redirected to Blue Ridge Rural Water Company's website.

A copy of the completed draft form will be sent to your email provided for your records.

Thank you for your time.