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Authorization Agreement for Automatic Payments
This application is for automatic withdrawal of utility payments from a Checking or Savings Account using a bank routing and account number ONLY.
Checking/Savings Automatic Payment Application
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.
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.
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.
This field is not part of the form submission.
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