This form is available only in downloadable format. You cannot fill it out online or submit it electronically.

To sign up for CWLP bill payment through automatic bank account withdrawal, click on the form graphic below to open a full-size copy of the form, which you can print, complete and return by mail or in person to:

Be sure to sign the form and include a voided blank check or deposit slip when you return it.
 

Click on the form graphic (right) to open a full-size copy of the Automatic Withdrawal Authorization Form.
		To view and print this form, you need Adobe Acrobat or Acrobat Reader. To obtain a free copy of the latest version of Acrobat Reader, click this icon: