Customer Information Select type(s) and provide appropriate account number(s) General Billing General Billing Customer Number Sewer Utility Sewer Utility Sewer account number Individual/Company Name * Accounting/ACH Contact Name Address * City * State * ZIP Code * Phone * Fax Email Address for Form Confirmation * Once enrolled, billing statements will be sent to this email address. Above named Customer hereby authorizes Sussex County to initiate Automated Clearing House electronic funds transfer (EFT) debit entries to Customer's account, as indicated below. Banking Information Account Type * Checking Savings Account Action * New Setup Change Name on Bank Account * Bank Routing Number* * Bank Account # * Bank Name * * Provide the 9 digit bank routing number from a check. The routing number from a deposit slip is invalid. This authority is to remain in full force and effect until Sussex County has received notification from an authorized person for this account of its termination in such time and manner as to afford Sussex County and your Bank a reasonable opportunity to act on it. Customer Authorization THE ENROLLMENT FORM MUST BE RECEIVED AT LEAST 15 DAYS PRIOR TO PAYMENT DUE DATE. Authorized Name/Title * Initials * Date Year Year20242025 Month MonthDecJan Day Day12345678910111213141516171819202122232425262728293031 Comments/Notes Leave this field blank
