Water/Sewer/Garbage Form: Direct Payments (ACH Debits) Authorization Agreement

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Direct Payments via ACH is the transfer of funds from an account for the purpose of making a payment. *

Begin Payment

Change Information

Account Name: *

Utility Account Number: *

Service Address: *

Cell Number: *

Email Address: *

Account Type: *

Checking Account

Savings Account

Depository (Bank) Name: *

Routing Number: *

Account Number: *

Terms and Conditions: *

Yes

I (we) hereby authorize CITY OF DAWSONVILLE, hereinafter called COMPANY, to initiate debit entries to my (our) checking and/or savings account indicated above at the depository financial institution named above, hereafter called DEPOSITORY, and to debit the same to such account on the 10th of each month. Debits will be monthly for the balance due on the account, which can/will vary by month/usage. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Voided Check: *

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Signature: *

Date:

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Water/Sewer/Garbage Form: Direct Payments (ACH Debits) Authorization Agreement

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