Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Auto-Pay Authorization

  1. Terms of Agreement

    I authorize Cross Valley Water District to automatically withdraw from my account, as identified below and with the voided blank check copy attached to this form, for the amount due on my next bi-monthly bill. I also authorize the below named Financial Institution to accept Preauthorized Electronic Fund Transfers initiated by Cross Valley Water District (CVWD) on a recurring basis. I certify that I am an authorized signatory for the financial institution account provided to the District for Autopay.  Customers requesting Autopay from a savings account must provide either a pre-printed deposit slip or a letter from your financial institution acknowledging you are an authorized signatory on the account.


    I understand that Autopay payments will be withdrawn from my account on the 20th day of the month following the billing date, or depending on weekends and holidays, up to five business days later. I understand that if I dispute the amount billed, I must contact the District five business days prior to the 20th day to stop the scheduled payment.


    I understand that I will continue to receive my regular bills with a notation of Autopay status printed on the bill. Autopay is a recurring service and cannot be used for a one time automatic payment and Autopay payments cannot be re-scheduled for another payment date. I understand that I may not make Payment Arrangements when using Autopay. I understand that failure to receive a bill does not relieve a customer of the responsibility for payment and penalties per CVWD 9.05.160. I understand that I can cancel Autopay or change my account information by writing or emailing the District at least five business days prior to my next scheduled Autopay payment date.


    I understand I am responsible to ensure sufficient funds are available in my bank account at the time of the Autopay payment. If my Autopay payment is returned by the bank for any reason, I will be charged a returned item fee.


    I understand that if an erroneous withdrawal occurs, I must contact both my Financial Institution and Cross Valley Water District to notify them of the error. The District shall have up to ten business days from my initial contact to research and respond to a customer’s notice of an error. The District may require the customer to provide a written explanation of the Autopay payment error.


    I certify under penalty under the laws of the State of Washington that the statements and information provided by me are true and correct.

  2. Leave This Blank: