Customer Number*

Customer Name:*

First Last

Service Address:*

Street Address Address Line 2 City State ZIP Code

Contact Phone Number:*

Email Address: (Optional)

Last 4 Digits of the checking/savings account that I wish to remove the automatic draft from*

By submitting this form, I authorize Daphne Utilities to deactivate the automatic bank draft feature on my account. I understand that this change will be in effect within two business days from the date of this request.

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Bank Draft Cancellation Request

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