Account Number:________________________
Date:__________________________
Residential:_____ Commercial:____
OPTIONAL
P.O. Box 826
Cibolo, TX 78108
210-658-9900
www.Cibolotx.gov
City of Cibolo Automatic Payment Agreement
Name: _________________________________________________ Cell Phone:_____________
Service Address: _________________________________________ Add. Phone:_____________
Email Address: ________________________________________________________________
1. I
hereby authorize the City of Cibolo to automatically charge my account once per calendar month, on the due date
or business day prior should the due date fall on a weekend or holiday, for all accounts due on my monthly utility
account. I understand that the amount of my monthly utility bill varies based on monthly consumption and
current rates. I also understand that I will continue to receive a monthly utility bill, with the withdrawal date
printed on the utility bill.
2
. This procedure will remain in place unless and until I give the City of Cibolo 30 days written notice that I elect t
o
t
erminate this service and resume normal monthly billing.
3
. I further authorize a $25.00 charge to my account in any case in which the automatic charge is rejected because
my specified account has either been closed or there are insufficient funds to cover the charges owed. After two (2)
incidents, I will be terminated from automatic payments and placed on a CASH ONLY basis.
4. I
agree to give the City of Cibolo prompt written notice of any change in my account, and understand that Cibolo
must receive notice by the 1
st
of the month in order for it to be effective as part of that month’s billing cycle.
Notices received after the 1
st
will go into effect on the next month’s billing cycle.
5. T
he City of Cibolo has the right to terminate automatic payment service at any time with written notice to
customers. This agreement will remain in effect until cancelled by either party.
This agreement authorizes the City of Cibolo to automatically deduct the balance of my utility account from the bank
account listed below for the utility account listed above. I declare that the account number given belongs to me, and that
any changes to or cancellation of the automatic payment plan will be made strictly by me.
Customer Authorization: _____________________________________________________ Date: _________
F
inancial Institution Information (please type or print the following information):
Financial Institution Name: ________________________________________________________________
Name(s) Appearing on Account: _____________________________________________________________
Account Number: __________________
Routing Number: __________________
Type of Account*: Savings Checking
*The City is not responsible for any payment processing errors or fees incurred if you do not provide accurate billing account
information including a copy of a voided check or a letter from your financial institution.
