Bank Draft Application

Name*

First NameLast Name

Authorization Type *

Utility Account # Account Number*

Utility Account Customer Name Customer Name*

Service AddressService Address*

Mailing Address Mailing Address*

Contact Phone# Phone #*

Bank Name/AddressBank Name & Address*

Bank Account NumberBank Account #*

Bank Routing/ Transit NumberRouting and Transit *

I authorize my financial institution to debit my bank account each billing cycle and credit/pay the Edgecliff Village City for utility service on the bank account referenced above. I understand that a fee will be charged by the City for all transaction resulting in insufficient/unavailable and that my utility service will continue to be subject to late fees and disconnect for failure to pay a bill by the due date. I understand and agree that the city shall not be responsible for errors or omissions of my Financial Institution, and that my obligation to timely pay a utility bill remains in force regardless of errors and omissions by the Financial Institution. I have the right to discontinue participation by notifying the City in writing at least seven (7) business days prior to the due date of payment. If I elect to discontinue participation, i will still be responsible for the payment of my bill due date. I further understand that both my Financial Institution and the City reserve the right to terminate this Automatic Bill Payment Agreement or my participation at any time without prior notice.

Any balance due on your utility account should be paid prior to startup of the Automatic Bill Payment program. If the balance is not paid, the first automatic withdrawal from your bank account will deduct the entire amount owned on your utility account. The City must be notified immediately at any time you change Financial Institution or bank account information in order to prevent returns on payment request. Your checking/ savings account will be drafted anytime from the 17th - 20th of each month. You will know that the automatic withdrawal request is in effect once the statement "BANK DRAFT BILL - DO NOT PAY" appears on your utility statement.

Your Financial Institution may require you to fill out additional documentation to initiate this program. Some Financial Institution may also include a charge or fee for processing automatic payments. Please check with your Financial Institution for any such additional program requirements.

Agreed and Accepted by: *

Please verify that you are human*