ACH Bank Draft Authorization

This is an automatic payment option for your utility bill with no service fees. Your payment will be drafted from your bank account on the 10th of each month, or the next business day if the 10th falls on a weekend or holiday. Forms must be submitted by the 25th to start autopay the following month.

Name of bank or other financial institution:*

Routing Number:*

Bank Account Number:*

Confirm Account Number:*

Please select one of the follow:*

Checking AccountSavings Account

I (we) hereby authorize the City of Josephine to automatically draft my (our) bank account for payment of my (our) monthly utility bill. This authorization will remain in effect until written notice of termination is provided by me (us) and received by the City.
I (we) understand that this authorization does not relieve me (us) of the responsibility to ensure timely payment of my (our) utility bill. If sufficient funds are not available in the designated account to cover the draft amount, utility services may be subject to disconnection.

I agree and understand to the above terms and conditions.*

Agree

A $30.00 fee will be applied to all returned payments. After three (3) returned payments within a 12-month period, automatic drafting privileges will be cancelled. I (we) will be required to make manual payments for the next twelve (12) months before being able to re-enroll in ACH Bank Draft.

I agree and understand to the above terms and conditions.*

Agree

Print name as it appears on bank account:*

Utility Account Number:

Ex. 1-1111-11

Service Address:*

Email Address:*

Phone Number:*

I understand that this form must be submitted by the 25th to start ACH Bank Draft for the next month’s bill on the 10th. If submitted after the 25th, I agree to make a manual payment for the upcoming bill, and ACH Autopay will begin with the following bill. I understand that if I ever choose to cancel my ACH bank draft authorization in the future, the City must receive a completed ACH Cancellation Form at least three (3) business days prior to the scheduled draft date to avoid an automatic withdrawal.*

I agree and understand.

Signature*

Date

Hour MinutesAM/PM Option