ACH Payment Application

Authorization for Automatic Payments of Water and Sewer Utility Bills (Complete this form and upload a VOIDED check or Letter from Bank)

Name*

Service Address*

E-mail Address*

Phone Number*

Address*

Bank Name*

Bank Address

Will you be paying from a Checking Account or Savings Account?

Checking

Savings

Routing Number*

Account Number*

I authorize you to deduct from my checking/savings account the amount of any City of Freeport water/sewer bill and to make that deduction payable to the City of Freeport. In making this authorization, I agree to all the terms as listed below. **I authorize the financial institution named on this form to pay my water and sewer utility bill by charging each payment to my account. I agree that each payment shall be the same as if it were an instrument personally signed by me. This authority begins immediately and will remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my financial institution prior to charging my account. I understand, however, that both the financial institution and City of Freeport reserve the right to terminate this payment plan (or my participation therein). **All direct payments will be processed within 5 days prior to the due date stated on your monthly water bill (between the 10th and the 15th of the month). **Any payment returned for any reason will incur a $25.00 returned item fee. **The first bill of a new account and the final bill WILL NOT be bank drafted.

Signature*

Date*

Voided Check or Letter from Bank*

Please upload a copy of your ID for verification purposes*

Comments or Questions*