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Authorization Agreement for Automatic Payments

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  2. COP Logo
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  4. Authorization Agreement for Automatic Payments

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

  6. Customer Information

  7. Mailing Address (if different from service address)
  8. Checking/Savings Automatic Payment Application

  9. 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.

  10. Account Type*
  11. Electronic Signature Agreement*

    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.

  12. 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.

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  14. This field is not part of the form submission.