UTILITY BILLING AUTO-PAY ACH AUTHORAZATION FORM
Please fill out the information below. A member of the Town will contact you if any further information is needed.
CUSTOMER INFORMATION
CUSTOMER NAME (MUST MATCH NAME ON BANK ACCOUNT)
*
UTILITY ACCT NUMBER
*
UTILITY LOCATION NUMBER
BILLING ADDRESS (MUST MATCH ADDRESS ON BANK ACCOUNT)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TELEPHONE NUMBER
*
Format: (000) 000-0000.
FAX NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL ADDRESS
*
example@example.com
HOW WOULD YOU LIKE TO RECEIVE YOUR BILLS & PAYMENT RECEIPTS
*
Email
Postal Mail to Billing Address on File
Postal Mail to Temporary (Seasonal) Address
IF YES TO TEMPORARY ADDRESS, LIST END DATE
-
Month
-
Day
Year
Date
TEMPORARY BILLING ADDRESS
BILLING CONTACT (IF DIFFERENT FROM ABOVE)
BILLING CONTACT PHONE
Format: (000) 000-0000.
BILLING CONTACT EMAIL
example@example.com
FINANCIAL INSTITUTION INFORMATION
BANK NAME
*
BANK ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NAME ON ACCOUNT/ACCOUNT NAME
*
ACH ROUTING NUMBER (9 DIGITS)
*
ACH BANK ACCOUNT NUMBER
*
ACCOUNT TYPE
*
Checking
Savings
Business Checking
Business Savings
TAKE PHOTO/ATTACH IMAGE OF VOIDED CHECK
*
CERTIFICATION & AUTHORIZATION
I certify I am responsible for notifying any changes to the information provided above to the Town of Shipshewana.
I certify that I agree to immediately return any erroneous transactions that may occur as a result of payment via ACH.
I certify the information provided on this form is true and correct, and that I, as an authorized representative for the above-named company or customer, herby authorize the Town of Shipshewana to electronically pull payments from the designated bank account and, if necessary, initiate adjustments for any transactions credited or debited in error. This authorization remains in full force until written notice of change or cancellation is received by the Clerk-Treasurer of the Town of Shipshewana. The Town of Shipshewana reserves the right to cancel or suspend this authorization at any time.
AUTHORIZED OFFICIAL NAME (PLEASE PRINT)
*
TITLE (IF APPLICABLE)
AUTHORIZED OFFICIAL SIGNATURE
*
DATE
*
-
Month
-
Day
Year
Date
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