Automatic Bank Draft Request - City of Temple Utilities

City of Temple - Utility Business Office

Automatic Payment Authorization Form

Utility Account Holder Name *

Utility Account Number * 🛈

Utility Service Address *

Phone Number *

Email Address *

Financial Institution Name *

Financial Institution City, State *

Type of Account *

Routing Number *

Account Number *

Name as it Appears on the Financial Account *

Please attach a copy of a voided check for checking account verification. * 🛈

Acknowledgement *

I authorize the City of Temple to debit my account each month for the services billed on the utility account listed above. I understand that this authorization will remain in effect until I notify the Utility Business Office, in writing, at least 10 days prior to the next draft date. I certify that I am an authorized user of this financial account and will not dispute these automatic payments. Automatic payments will be drafted on the due date reflected on the monthly utility bill. Please note that the autopay date will vary, depending on weekends and holidays. The amount to be withdrawn and the autopay date will be reflected on the monthly utility bill. A charge of $30.00 will be assessed to the utility account for payments returned by the bank, for any reason. The City of Temple will cancel automatic payments if three payments are returned within a 12-month period. A returned payment acts as non‐payment on the utility account and services may be interrupted if payment isn’t cleared by the original disconnect date.

Name *

Date Signed * +