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2. Water Account No.*
3. Full Name*
5. Phone Number*
6. Email Address
8. If I have a current bill it should be automatically withdrawn.*
   -- Select One --YesNo
10. I authorize the Lafayette Utility Billing Office to stop my Automatic Bank Draft payment option. I understand that my bill will no longer be paid automatically and that I will need to remit payments to the Utility Billing Office by the due date shown on my monthly statement.*

    1. I Agree
    2. I Disagree
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12. 1. Receive an email copy of this form.
13. Email address

    This field is not part of the form submission.

14. Submit

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