51114-03 7/24/2020
Application for Pre-Authorized Utility Payments
I hereby authorize the City of Alexander City to initiate debit entries to my checking/savings account for payment of my
utility account(s). Further, the City of Alexander City, Alabama, may, if necessary, credit entries and adjustments for any
debit entries in error. This authority will remain in full force and effect until the Utility Business Office in a manner as to
afford the City of Alexander City and the Depository a reasonable time to act upon it has received WRITTEN notification
of termination. If you need assistance completing this form, please call (256) 329-6710.
Utility Account(s) Information:
Name: __________________________________________________
Utility Account Number(s): ___________________________________________________________________________
Contact: Cell: (____)________________ Home: (____)________________ Work: (____)_______________
Service Address: ____________________________________________________________________________________
Financial Institution Information:
Institution Name: __________________________________ Type of Account: _____ Checking _____ Savings
Routing Number: __________________________________ Account No.: _________________________________
Start Date for Auto Draft: ______________________
There is no additional charge for this service. However, in the event that debit entries are rejected by the Depository due
to insufficient funds or account closed, the return will be treated as any other rejected entry and our normal service
charges shall apply. Further, should this occur, all rules and regulations applicable from Chapter 90, UTILITIES, of the Code
of Ordinances of the City of Alexander City, Alabama, shall apply.
__________________________________ ____________________________________ ______________
Print Name Signature Date
P.O. Box 552 • Alexander City • Alabama 35011‐0552 • (256) 329‐6700
Attach a Voided Check Here
**Payments are drafted about 5 days after the statement due date.
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