I authorize the Temple Water Department to include:

______ $5.00 ______ $10.00

______ $15.00 ______ $25.00

Or $______ in my water bill each month for membership to Keep Temple Beautiful, Inc. I understand that this will become effective with my next water bill and will remain in effect until I notify the Water Department in writing to change the authorization.


__________________________________________________
Name on Water Bill

__________________________________________________
Account Number on Water Bill

__________________________________________________
Address of Your Water Service

__________________________________________________
City State Zip

__________________________________________________
Telephone Number

__________________________________________________
Signature / Date