Automatic Bill Payment Authorization

What is automatic bill authorization and how does it work? It’s an electronic funds transfer payment that saves you the trouble of writing a check to pay your bill. After you have signed up, you will receive your bill marked “PAID BY DRAFT” each month and it will be deducted out of your checking account on the 15th of each month. If the 15th should fall on a holiday or weekend, your payment will be deducted on the following business day. We notify your bank or financial institution of the amount to be transferred from your account to pay your water bill.

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I (we) hereby authorize City Of Story City Water Department to initiate debit entries to my (our) checking or savings account (ACCOUNT TYPE, as selected below) in the financial institution (BANK) named below. I (we) further authorize BANK to debit such entries to my (our) account.

Account Type(Required)

Checking

Savings

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Bank Account Number

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Bank Routing Number

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Bank Account Number(Required)

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Bank Routing Number(Required)

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Bank Name(Required)

Branch(Required)

Bank Address(Required)

Street Address City State ZIP Code

Bank Phone(Required)

It is understood that this agreement may be terminated by (either of us) at any time up to seven says before the 15th of the month by oral and written notice to CITY OF STORY CITY WATER DEPARTMENT. Any such notification to CITY OF STORY CITY WATER DEPARTMENT shall be effective only with respect to entries initiated after receipt of such notification.

I agree that I remain obligated to pay for water services in the event that a charge to my account is dishonored, for whatever reason, and the City of Story City Water Department retains its normal collection rights.

Depositor's Name(Required)

Email(Required)

Depositor's Address(Required)

Street Address City State

Depositor's Phone(Required)

Depositor's Signature(Required)

Date(Required)

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Phone

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Automatic Bill Payment Authorization

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