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6. Authorization Agreement for Automatic Payments

8. This application is for automatic withdrawal of utility payments from a Checking or Savings Account using a bank routing and account number ONLY.

10. Customer Information

14. First Name*
15. Last Name*
17. Service Address*
18. Utility Account Number
20. Contact Phone*
21. Contact Email
23. Mailing Address (if different from service address)
25. Street Address
26. City/State/Zip
28. Comments

32. Checking/Savings Automatic Payment Application

36. Please note, to have a current outstanding utility bill drafted on the due date, this form must be submitted by the 1st of the month.

38. Bank Name*
39. Name as Shown on Account*
41. Routing Number*
42. Account Number*
44. Account Type*

    1. Checking
    2. Savings
45. Date*
47. Electronic Signature Agreement*

    1. I Agree

    By checking the "I agree" box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    
    

49. Signature*

    I/We understand by signing, certify the account number listed above is correct. I/We authorize the City of Pipestone to initiate debit or credit entries for payment of my/our utility bill on the due date, and for the banking facility indicated above debit or credit the same to such account. I/We understand that upon receipt of a draft returned due to insufficient funds in my/our checking or savings account, the City of Pipestone may cancel the drafting of my bill and charge applicable fees.

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit Submit and Print

* indicates a required field