Auto Pay (ACH) Utility Application Form

Auto Pay (ACH) Utility Application Form

This is an optional, free program of recurring payments through your bank account. Your bill will reflect "Auto-Pay customer" upon being added to this program.
Utility Account Name*
Enter the name as it appears on your Utility Bill
Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enter Your Email *
example@example.com
Utility Billing

Enter the account numbers to be Auto-Paid with the checking/savings account . If you require more than five accounts or wish to pay using multiple accounts, you must submit multiple forms.
Utility Account Number*
This is located on your utility bill
Utility Account Number
Utility Account Number
Utility Account Number
Utility Account Number
Fees

Currently Savings and Checking are Free. (Subject To change)
Payment Account Type*

CheckingSavings
Financial Institution Name*
Name on the Account*
Bank Routing Number*
Bank Account Number*
You must UPLOAD an image of your voided check - or - the header from a current savings account bank statement. This is to ensure integrity in setting up your account properly use your cell phone to photograph the document, then email it to your computer and use the widget below to upload it. Forms submitted without these documents will be rejected*

Cancelof
Authorization Agreement for Automatic Cash Transfer I hereby authorize the financial institution I have named on this application to charge the account I have specified for payment on my CITY OF EASTON utility bill. I agree that this includes all outstanding balances as well as current invoices. The full balance due will always be deducted on each due date. I authorize each charge to my account shall be the same as if I had signed a check to pay my bill. I have the right to stop payment of a charge by notifying the CITY OF EASTON within 15 (fifteen) days prior to the due date of my bill. In addition, I understand that both the financial institution and/or CITY OF EASTON reserve the right to terminate this payment plan at any time. Also, I may elect to discontinue my enrollment in this plan at any time.
I Authorization* Agree to the terms listed above and Authorize Auto-Pay of my Utility Bill as defined above.
EBILL - Save $1*

I Wish to go Paperless and receive my Bill via email.I DO NOT wish to go Paperless and save a $1
Auto-Pay

By signing up for this option your bill will have a designation on it identifying it as Auto-Pay. If you sign up after the 10th of the month your Auto-Pay will NOT BE ACTIVE until the next bill cycle.
Name of Person Filling Out this Form.*

First NameLast Name
Please verify that you are human*
Should be Empty:

Auto Pay (ACH) Utility Application Form

Utility Billing

Fees

Auto-Pay