Bank Draft Authorization Form

Bank Draft Authorization Form

I authorize my financial institution indicated below to debit such amounts from my bank account. I understand that my account will be paid by draft until such time as I provide written notification to the City of Canyon Business Office.
Drafts submitted by the 8th of the month will process the current month on the 15th.

Drafts submitted after the 8th, will draft the following month on the 15th.
NewChangeStop
Start Date*

MonthDayYear
Date
Name*

First NameLast Name
Name of Business, if applicable

First NameLast Name
Service Address*
Utility Account Number*
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Financial Institution Information

Upload a voided check or savings account form with this application. Please note that you will continue to receive a monthly statement, however, the statement will show your current bill with “PAID BY DRAFT” printed below the amount due. Returned Draft Fee: $25 plus your bank institution fees. If you have two returned drafts within a 12-month period, you will no longer have the option to pay by draft.
Name of Bank*
Address of Financial Institution*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CheckingSavingsOther
Routing Number*
Nine digits
Account Number*
Voided Check or Savings Account Form

Cancelof
Signature

Clear
Should be Empty: