Utility Bill Automatic Payment Enrollment Form

Name*

First NameLast Name

Business Name

Utility Account Number*

Enter the account number exactly as it appears at the top of your utility bill.

Utility Service Address*

Street Address

CityState / Province

Postal / Zip Code

Any additional utility accounts that you want to enroll in auto pay?

YesNo

Additional Utility Accounts

Phone Number*

Area CodePhone Number

Email Address*

example@example.com

Name of Bank*

Name(s) on Bank Account*

Account to be Charged*

CheckingSavings

Routing Number*

Account Number*

By submitting below, I (We) hereby agree to the following acknowledgments.

ACKNOWLEDGEMENTS
I (We) agree to the terms and conditions outlined herein.

I (We) hereby authorize City of St. Petersburg (the “City”) to automatically initiate debit entries (charges) to my bank account (and for my bank to accept and post such debit entries) for the payment of all utility bills rendered to me by the City. The City does not charge a fee for this service and I understand my bank may.

I (We) understand this application will be processed upon receipt. Any current balance owed must be paid by the due date to avoid penalties. If there remains a past due balance owing, it will be deducted with my next month’s bill.

I (We) understand that automatic bill payment may take up to one (1) billing cycle to become active. A message will appear on future bills notifying me of the automatic bill payment.

I (We) understand the City will debit my account on the due date of the bill. I (We) understand that the City will continue to render a bill and both the City and my bank may impose a fee in the event a debit entry is not paid by my bank.

I (We) understand this authority will remain in effect until the City has received written notification from me (us) of its termination in such a manner as to afford the City and my bank a reasonable opportunity to act on it. I (We) have the right to stop payment of charge entries by notifying the City in writing seven (7) days prior to the due date reflected on the utility bill.

I (We) agree not to dispute the City’s recurring billing with my bank. Any erroneous or incorrect charge will be corrected upon notification to the City. If corrections in the debit account are necessary, it may involve a credit or debit to my account.

I (We) guarantee and warrant that I am a legal account holder for this bank account, and that I am legally authorized to enter into this recurring billing agreement with the City.

Under Florida Statute 119 (Public Records) your email communications may be subject to public disclosure. By clicking Submit, you agree that all information is true and correct to the best of your knowledge.*