Automated ACH Form

City of Lake Lotawana

Today's Date *

Bank Routing Number *

By entering my full name I authorize the City to withdrawl funds from my bank account. *

Branch Address *

UTILITY BILL ACH AUTHORIZATION FORM

Utility Account Number *

I authorize Lake Lotawana to debit my checking or savings account from the financial institution listed below for monthly payment of my sewer bill. This authorization is to remain in full force until Lake Lotawana has received written notification from me of its termination. I (we) understand that I am responsible to verify that the debit was properly made and that it was for the correct amount. In the event of an error, I (we) will contact Lake Lotawana as soon as possible. I understand that there is a $ .40 fee added to my bill each month for this convenience. *

Yes I authorize this and understand there is a .40 cent fee added each month.

Mailing Address, City, State, Zip *

Customer Name(s) as they appear on your bank account *

Property Address *

Phone *

Bank/Depository Name *

Bank Account Number *

City of Lake Lotawana

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