Utility Billing Authorization Agreement for Pre-Authorization Payments (Debits)

Name*field type single line
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Address*field type single line
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Service Addressfield type single line
(if different than mailing address)
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Phone*field type single line
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Email*field type email

Bank Account Information

Customer Account Name*field type single line
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Depository Institution*field type single line
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Depository Institution City/State*field type single line
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Bank Routing #*field type single line
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Bank Account #*field type single line
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File Uploadfield type file upload
Picture or scan of voided check
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I (We) hereby authorize the City of McHenry to initiate debit entries to my account for water and/or sanitary sewer service and to initiate, if necessary, credit entry adjustments for any debit entries made in error to my (our) account indicated below, and the depository institution named above.
The authority is to remain in full force until the City of McHenry has received written notification from me (us) of its termination.
Signature*field type signature
Date*field type date