ACH AUTHORIZATION AGREEMENT
City of Harrisonburg, Virginia
Automatic Payment Plan
I (we) hereby authorize the City of Harrisonburg, Virginia, hereinafter called City, and my (our) financial
institution to automatically pay my (our) monthly utility (water, sewer, refuse and solid waste management
collection) bill from my (our) checking or savings account. Enclosed is a voided check, for the account checked
below, which contains my (our) depository’s address, routing (ABA) number and my (our) account number.
CUSTOMER INFORMATION
Customer’s Name: _________________________________ Utility Account #: ______________________
Service Address: ________________________________________________________________________
Daytime Telephone Number: _________________
Billing Address: _________________________________________________________________________
Email Address: ______________________________________
CUSTOMER’S DEPOSITORY / BANK INFORMATION
Bank Name: _________________________________________
Bank Address: ___________________________________________________________________________
Routing Number: _________________________________ Bank Account Number: __________________
Type of Account: Checking Savings
Attach a voided check and sign this form in order for the City to process your information. The City will
notify you, by message on your bill, of your Automatic Payment start date.
The City of Harrisonburg Public Utilities conducts business in accordance with the City Ordinance (Sec 7-1-9 &
7-4-1.4) and retains the right to remove a customer from the Automatic Payment Plan for just cause.
It is the customer’s responsibility to assure sufficient funds at the time of withdrawal. The Utility Billing
Department will make every effort to forward any information provided by your banking institution; however, we
cannot guarantee advanced or delivered notice to avoid penalty or delinquencies. By authority of this form, I
accept full responsibility without justification for waiver.
This authorization will remain in effect until the City has received written notification from me (us) at least
ten (10) business days prior to the requested cancellation date.
Customer’s Signature: ________________________________ Date: ____________________________
**FOR INTERNAL OFFICE USE ONLY**
Received / Input by: _____________
Verified by: ____________________
