Fillable AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS) (City of Port Washington)

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AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS) (City of Port Washington)

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CITY OF PORT WASHINGTON
100 West Grand Avenue P.O. Box 307 Port Washington, WI 53074
Phone: (262) 284-2600 ext. 1004
Email: snelson@cpwwi.org
www.CityofPortWashington.com
CITY OF PORT WASHINGTON
AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)
I (we) hereby authorized the City of Port Washington to initiate debit entries to my (our) account specified below at the depository
financial institution named below (hereinafter called DEPOSITORY) and to debit the same to such account. This authorization is to
remain in full force and effect until the City of Port Washington has received notification from me (us) of its termination in such time
and in such manner as to afford the City of Port Washington and the Depository a reasonable opportunity to act on it.
If you choose to change your payment method to our online bill pay system, Payment Service Network, please sign up at
www.cityofportwashington.com
. PLEASE NOTE: Signing up to pay online DOES NOT cancel this ACH Debit agreement. You MUST
contact our office at 262-284-5585 to cancel this agreement, to prevent additional payments from being debited from your
account.
CUSTOMER INFORMATION
NAME____________________________________________
PHONE__________________________________________
ADDRESS__________________________________________
WATER ACCOUNT_________________________________
SIGNATURE________________________________________
DATE___________________________________________
BANKING INFORMATION
DEPOSITORY NAME_________________________________
BRANCH_________________________________________
CITY______________________________________________
STATE _______________________ ZIP _______________
ROUTING#_________________________________________
ACCOUNT #______________________________________
N CHECKING SAVINGS
OFFICE USE ONLY
DATE SET UP _______________ DONE BY______________
Please return completed form to City Hall for processing
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AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS) (City of Port Washington)

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Completed 20 August 2020

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