| Is the automatic payment plan for you?
It is if you like to 1) save TIME 2) save MONEY. |
| The automatic payment plan allows your
utility bill to be paid direct ely from your bank account
on the due date of the bill every month at no cost, regardless
of where you bank. Simply complete the form and return
it to City Hall. Call 885-6555 for more information. |
| AUTOMATIC PAYMENT PLAN PREAUTHORIZATION AGREEMENT |
| Name: |
_________________________________________________________ |
| Service Address: |
_________________________________________________________ |
| Telephone #: |
_________________________________________________________ |
| Customer Account #: |
_________________________________________________________ |
| FINANCIAL INSTITUTION |
| Name: |
_________________________________________________________ |
| City: |
_________________________________________ State: ___________ |
| Bank Account #: |
_________________________________________________________ |
| I / We authorize the City of Shell Rock
to receive automatic payment for my/our utility bill.
It is also agreed the Financial in named above
will debit my account |
| Signature: |
__________________________________________Date:___________ |
| |
|
| If you have multiple services, please call
City Hall at 319-885-6555 to obtain additional forms. |
| Return this form to: |
Shell Rock City Hall
P.O. Box 522
Shell Rock, IA 50670 |
