Hanover County Department of Public Utilities
Auto Pay Authorization Form
To enroll in Auto Pay, please complete all sections printing neatly and legibly, sign the authorization section and return this form
with a voided check to Hanover County Department of Public Utilities, P.O. Box 470, Hanover, VA 23069. If you have any questions,
contact customer service at (804) 365-6024.
Select Application Type ☐New application ☐Updated application
Utility Account Number: _____________________________ - _______________________________
Name on Account: ________________________________________________________________
Service Address: ________________________________________________________________
Daytime Phone: ________________________________________________________________
Direct Payment Bank Information and Authorization
Bank Account Type □ Personal □ Business Please Enclose a Bank Check Marked “VOID”
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_____________________________________________________
Name on Bank Account
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_____________________________________________________
Checking Account Number
F
or the purpose of utility bill payment, I/we hereby authorize Hanover
County to initiate debit entries and/or correction entries to the account and financial institution named herein and authorize the
financial institution to honor these entries. I/we understand that I/we must continue to remit my/our payment by check until such
time as the bi-monthly bill indicates that bank draft is active.
I
understand the authorization is to remain in full force until Hanover County has received written notification of its termination, at
least ten (10) business days in advance of the next scheduled payment. I/we also understand the County may stop my participation
in this service if necessary.
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____________________________________________________
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____________________
Signature of Bank Account Holder Date
What is Auto Pay? Auto Pay allows you to have your utility payment automatically deducted from your bank account 30 days
after the bill date.
Who is eligible? Auto Pay is open to all customers whose account is in good standing. There is no charge to participate.
How do I know when it is active? Your automatic payments will begin when you receive a message on your bill stating “Your bank
account will be drafted for the total amount due on the due date.” The draft date is 30 days after your bill date.
What happens in the event of a rejected payment? Payments made under this program will be processed based upon policies and
ordinances governing payments made by check, which includes a returned payment fee.
Once enrolled, how do I change information? Changes in information need to be submitted in writing. Hanover County Public
Utilities will not be responsible for losses that result from inaccurate information or failure to provide us with timely notification of
changes.
How do I stop Auto Pay? You may cancel your participation in Auto Pay at any time by mailing a written request to the above
address. Termination will become effective within ten (10) business days after receipt of notification.
For County Use Only
Reviewed By ______________________ Date ____________________
