PLEASE ATTACH A VOIDED CHECK TO THIS FORM Sample Clauses

PLEASE ATTACH A VOIDED CHECK TO THIS FORM. (PLEASE NOTE THAT WE CANNOT ACCEPT A DEPOSIT SLIP AS A FORM OF ENROLLING FOR BANK DRAFT.)

PLEASE ATTACH A VOIDED CHECK TO THIS FORM. By signing below, I agree to the terms of this Automatic Payment Agreement. Sign and Date

PLEASE ATTACH A VOIDED CHECK TO THIS FORM. For savings accounts please contact your financial institution for routing and account numbers.

PLEASE ATTACH A VOIDED CHECK TO THIS FORM. [Image Intentionally Omitted]

PLEASE ATTACH A VOIDED CHECK TO THIS FORM. This authorization shall remain in full force and effect until the City of Dodge City has received written notification from me (us) of its termination in such time and in such manner as to afford the City of Dodge City and the Financial Institution a reasonable opportunity to act on it. I understand that failure to ensure sufficient funds to cover the debit of my account for the amount listed on my utility bill is sufficient cause for termination of this agreement by the City of Dodge City. Additional charges may be assessed to my utility account and the City of Dodge City may terminate my utility services in such circumstance. Name (Please Print) Service Address (Meter location) Mailing Address Home Phone/Work Phone City, State, Zip Authorized Signature/Date LIST BELOW ALL ACCOUNTS TO BE AUTOMATICALLY DEBITED (Attach a second page if needed) City of Dodge City Acct No. City of Dodge City Acct No. Return the completed form to: City of Dodge City P.O. Box 880 Dodge City, KS 67801 CITY OF DODGE CITY BANK DRAFT MAKES PAYING YOUR UTILITY BILL EASY! City of Dodge City’s BANK DRAFT option allows the amount of your monthly utility bill to be automatically deducted from your bank account. There’s no check to write, no payment to mail, no more forgetting to pay – and best of all, BANK DRAFT will save you money. In fact, you will save money and time – no check writing costs, no postage expense, no more penalties and more time for you! Here are some things to keep in mind when using BANK DRAFT for your Utility Bill payments: ✓ Continue to pay your bill as usual until you see “Bank Draft – Do Not Pay” in the message section of your bill (lower left corner). The payment will come out of your bank account around the due date on your bill. This message indicates that the application process has been completed. ✓ We require written notification in our office at least one week prior to your “due date” to cancel an automatic payment. ✓ Automatic payments returned by your financial institution due to insufficient available funds will be treated the same as a returned check and will be subject to a return check charge. In addition, this automatic payment agreement may be subject to immediate cancellation. ✓ Refusal of payment by your bank may result in delinquency status, which could lead to penalties, a delinquency fee, and/or disconnection of your water meter. If you have any questions, please contact us at: City of Dodge City Utility Office (000) 000-0000 xxx.xxxxxxxxx.xx...