I, ___________________________________________ am requesting automatic bank or credit card drafting to be terminated at the following service address _______________________________________________________. I understand that an additional deposit may be required and that my drafting will not cancel until the additional deposit is paid. I am also aware that if I wish to restart drafting again in the future I will be required to complete a new drafting form.
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Customer Signature |
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Date |
An additional deposit is: _____ not required
_____ required in the amount of $_________________
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Lakeway MUD Authorized Signature
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I, __________________________________________ authorize Lakeway Municipal Utility District to charge my credit card for the additional deposit that is required to stop automatic drafting.
MasterCard Visa Discover American Express
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Credit Card Number |
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Expiration Date |
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_________________ |
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3 Digit security code |
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(Found
on back of card/MANDATORY) |
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Name on Credit Card |
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District Account Number |
Lakeway Municipal Utility District
1097 Lohmans Crossing
Lakeway, TX 78734
512/261-6222
512/261-6681 fax