City of Chappell
757 2nd Street - PO Box 487
Chappell, NE 69129
308-874-2401 Fax 308-874-2508

47-6006136
Company ID

I (we) authorize the above to initiate debit entries to my (our) checking / savings account indicated below and the names below to post the same to such account.

__________________________________________________________________________ Customers Bank Name - - - - - - - - - Customers Bank Address

_____________ _______ - (Subject to change upon notification by the City of Chappell)
Paymt Frequency - - Payment Amount

Disclosure
This authority is to remain in full force and effect until the City of Chappell has received written notification from me (or either of us), 30 days prior to termination and in such manner as to afford company a reasonable opportunity to act on it and in no event shall it be effective with respect to entries processed by the City of Chappell prior to receipt of notice of termination.

I (we) further authorize the City of Chappell to initiate such credit entries to said account as may be necessary to correct any erroneous debit entries previously initiated thereto. I (we) authorize the bank to accept and to credit ore debit the amount of such entries to my (our) account. I (we) shall within fifteen calendar days following the date on which the bank sent to me, a statement of account or a written notice pertaining to such entry, have sent to the bank a written notice identifying such entry, stating that such entry was in error and requesting the bank to reverse the amount thereof to such account.

I (we) have the right to stop payment of any entry by notification to bank prior to posting to the account.

The undersigned hereby agrees that all entries initiated hereunder are to be governed in all respects by the Rules of the Mid-America Payment Exchange as now or hereafter in effect and agrees to be bound thereby.

____________ ______________________________ ________________________
Date - - - - - - - Customer Signature - - - - - - - - - - - - Customer Signature

_______________________________ ________________________________
Customer Utility Account Number - - - - - Print Name

Please attach voided check