FULTON COUNTY FINANCE DEPARTMENT
WATER & SEWER BILLING AND COLLECTIONS DIVISION
141 Pryor St, Suite 7001, Atlanta, GA 30303
Phone: (404) 612-6830 Fax: (404) 612-2131
Email: ACHSignup@fultoncountyga.gov
New Enrollment
Change in Financial Institution
Secondary Phone
LAST Name, First Name, Middle Initial
Service Address
Name
(as shown on the bill)
AUTO BILL PAY/ACH (AUTOMATIC CLEARING HOUSE) FORM
Printed Name Signature
Primary Phone
Email
Fulton County Water/Sewer Account Information
LAST Name, First Name, Middle Initial
Financial Institution
Name
Name on the Financial
Institution Account
Customer Number Account Number
Financial Institution Information
Financial Institution
Address
Routing Number
Account Number
Type of Account
(check one):
Checking
Savings
I UNDERSTAND THAT:
• I must supply Fulton County with a voided check or deposit slip.
• I must sign this form for my application to be processed.
• Fulton County will send me a bill before my bank account is drafted.
• The bill amount will be drafted from my bank account on or
immediately following the due date shown on the bill.
• There will be a processing charge, if my direct payment is not processed
due to insufficient funds.
• I have the right to cancel my participation in the DIRECT PAYMENT
PLAN by notifying Fulton County in writing and by giving Fulton
County and my banking institution a reasonable amount of time to
process my request.
• Fulton County and my banking institution reserve the right to end my
participation in the DIRECT PAYMENT PLAN. I will be notified in
writing following termination.
Yes, please sign me up for Fulton County’s DIRECT PAYMENT PLAN for water and sewer services. I have
enclosed a voided check from my account at my banking institution. I have read and agree to the terms of
the plan. I have signed the application below.
Date
City
Street Address
State
Zip Code
City
Street Address
State
Zip Code
SAMPLE
• Print and sign the application;
• Scan and email the documents to ACHSignup@fultoncountyga.gov; or
• Fax it to (404) 612-2131; or
• Drop off in person at:
mm/dd/yyyy
o 11575 Maxwell Rd, Alpharetta, GA 30009; or
o 141 Pryor St SW, 7th Floor, Atlanta, GA 30303.
or
