To register for the draft, simply print this form, fill
it out and mail it to:
Happy State Bank, P.O. Box 1001, Happy, Texas 79042.
This is authority to draft my Happy State Bank account number for the
following services:
(circle all that apply).
My Happy State Bank account number is ____________________________________
| Service
| Account Number (if known)
|
| ATMOS ENERGY
| Acct. Num:
|
| CITY OF ____________
| Acct. Num:
|
| EXCEL ENERGY | Acct. Num:
|
| AT&T
| Acct. Num:
|
| SUDDENLINK CABLE
| Acct. Num: |
Please draft my account, beginning the month of _______________________,
200____.
I would like a copy of my bill mailed to my billing address after each
billing period .__YES__ NO.
The draft is drawn on Happy State Bank, P.O. Box 1001, Happy, Texas 79042.
Our transit routing number is: 111310870
I authorize the companies above and Happy State Bank to make automatic
payments monthly from the account specified on this authorization form.
_________________________________________ _________________________
Customer's Signature Date
_________________________________________
Print name as listed on bank account
_________________________________________ _________________________
Billing address Service address (if diff.)
_________________________________________ _________________________
City, State ZIP City, State ZIP
|
