City of St. Marys Sewer ACH Payment Authorization

City of St. Marys Sewer - Direct Pay
Authorization for Monthly Direct Payment via ACH (ACH Debit / Bank Draft)
Customer Name
1. Sewer Account # (xxxxx - xxxxx)
2. Sewer Account # (xxxxx - xxxxx)
3. Sewer Account # (xxxxx - xxxxx)
4. Sewer Account # (xxxxx - xxxxx)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
BANK NAME
Type of Account:

CheckingSavings
ROUTING NUMBER
ACCOUNT NUMBER
I authorize the City of St. Marys to electronically debit my checking or savings bank account designated above (and, if necessary, electronically credit my account to correct erroneous debits) for monthly bank draft payments. By signing below, I hereby indicate my acceptance of the terms of this agreement. I understand that this authorization will remain in effect until I notify the City of St. Marys of my revocation by submitting a written request to the City of St. Marys Sewer Office at 11 Lafayette St. St. Marys, PA 15857 or by calling our office phone line directly at 814-781-8452. The City must receive notice of revocation from you at least three (3) business days prior to the draft date in order to cancel this authorization.By signing below, I represent under penalty of perjury that I am an authorized signer and user of the bank account designated above and that I authorize the City of St. Marys to draft such bank account on the draft date specified above. By signing below, I also acknowledge receipt of a completed copy of this Authorization for Monthly Direct Payments via ACH (ACH Debit / Bank Draft) form.
AUTHORIZED SIGNER'S SIGNATURE

Clear
AUTHORIZED SIGNER'S NAME (PLEASE PRINT)
DATE

MonthDayYear
Date
- ALLOW UP TO 30 DAYS FOR PROCESSING-

11 Lafayette Street
St. Marys, Pennsylvania 15857
Phone: (814) 781-8452 · www.stmaryspa.gov · Fax (814) 834-1304
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City of St. Marys Sewer - Direct Pay

Authorization for Monthly Direct Payment via ACH (ACH Debit / Bank Draft)