Name: __________________________________________________________________

Address: ________________________________________________________________

State: ______________ Zip Code: __________ Phone #:__________________________

I have elected to go to the Direct Payment Plan of the following accounts:

Water & Sewer #___________________________

Electric #_________________________________

Bank Information:

Bank/Credit Union name and address: ________________________________________

Checking Account #______________________________

*Savings Account #______________________________

* If Savings account # is more than 9 digits then you must use a checking account.

PLEASE ATTACH A VOIDED CHECK WITH THIS APPLICATION:

                        Signing this form authorizes Swanton Village Inc to deduct the monthly billings indicated

above. The automatic payment will be deducted from your account Checking or Savings.

Signature: ____________________________________ Date: ______________________

         Please return to:SwantonVillage

PO Box279

Swanton,VT  05488

Phone: 802-868-3397