Authorization Agreement for Automatic Draft
I hereby authorize the City of Troy to initiate debit payment entries monthly on the payment
due date, to my account indicated below, at the financial institution named below. I understand
that this authorization is to remain in full force and effect until the City of Troy has received
written notification from me of its termination, in such manner as to afford it and the financial
institution named below to act on it.
City of Troy Account Number:_____________________________________________________
Customer Name:_______________________________________________________________
Customer Service Address:_______________________________________________________
Contact Phone Number:_________________________________________________________
Financial Institution:____________________________________________________________
City:_________________________________ State:__________ Zip:____________________
Bank Account Number:__________________________________________________________
Routing Number:_______________________________________________________________
Account Type:
Checking
Savings
Signature:____________________________________ Date:___________________________
PLEASE ATTACH VOIDED CHECK HERE
301 Charles W. Meeks Avenue · PO Box 549 · Troy, Alabama 36081 | Phone: 334.566.0177 | Fax: 334.808.7404
Email: utilitybilling@troyal.gov | www.troyal.gov
click to sign
signature
click to edit
![]()
