Automatic Payment Authorization Form

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Email *

Customer Name *

Service Address

Bank Name *

Routing Number *

Account Number *

Do you want a paper bill? *

Yes

Authorization Agreement

I hereby authorize and direct the City of Yutan to deduct my monthly sewer and water bill from the checking account listed above.

I understand the amount due will be automatically deducted from my account on the 5th day of every month or the next business day if the 5th falls on a weekend.

I agree that it is my responsibility to inform the City of Yutan of any account changes that may impact this payment.

I understand that a $25.00 charge will be assessed to my account if the automatic deduction is unsuccessful for any reason, including but not limited to insufficient funds, closure of my bank account, or incorrect reporting of any information on this form.

I understand if my payment is returned by my financial institution two or more times, I will be removed from automatic payments and required to remit a $150.00 security deposit at that time.

I authorize the City of Yutan to begin automatic payments. *

I approve of automatic payments

I DO NOT approve of automatic payments

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