Automatic Payment Authorization

Automatic Payment Authorization

Provide your bank and utility account details to set up monthly recurring ACH debits.
Bank Information

Provide your bank and utility account details to set up monthly recurring ACH debits.
Account Holder Name
Financial Institution Name
Routing Number (9 digits)
Account Number
Account Type
Utility Account Information
Name on Utilities Account
Service Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
ACH Debit Authorization
I hereby authorize City of Woodburn to initiate recurring debit entries to my account and financial institution named below for accrued utility payments. I acknowledge the origination of ACH transactions to my account must comply with the provisions of U.S. law and that I am liable for any costs incurred from my financial institution for any overdrawn payments made in this way. I request the debit entries to pay my current outstanding utilities balance in full and withdraw on the 10th day of each month (or the following business day if on a holiday).

This authority is to remain in full force and effective until City of Woodburn has received written notification from me of its termination in such time and in such manner as to afford City of Woodburn and the financial institution a reasonable opportunity to act on it.
Do you agree?
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Automatic Payment Authorization

Bank Information

Utility Account Information

ACH Debit Authorization