Utility Billing
Town of Cave Creek
P.O. Box 150
Cave Creek, Arizona 85327
Auto Bill Pay/ACH (Automatic Clearing House) Form
New Enrollment Change in Financial Institution
I (we) hereby authorize the Town of Cave Creek to initiate debit entires to my (our) account indicated below and the financial institution named below, hereinafter called Financial
Institution, to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.
Town of Cave Creek Utility Customer Information
_________________________________________ _______________________
Name(s) shown on utility bill Account Number
________________________________________________________________________
Service Address (Street, City, Zip)
_________________________________________ ________________________
E-mail Address Telephone Number
Financial Institution Information
__________________________________ _____________________
Name(s) on the Checking/Savings Account Financial Institution Name
_________________________________________________________________________
Financial Institution Address (Street, City, Zip)
________________ ______________________ Type of Account (check one): Checking
Routing Number Account Number Savings
Payments will be deducted from your financial institution account on the due date stated on your bill.
Automatic withdrawal will begin with the next billing cycle. Please continue to pay your bill until you see the
words “Direct Pay” on your monthly bill.
Based on the information above, I hereby authorize the Town of Cave Creek to initiate entries to my account at the financial institution name above, and authorize that financial institution
to debit my account for those entries. This authority is to remain in full force and effect until the Town of Cave Creek has received written notification from the customer at least 30 days in
advance of the next scheduled payment. I have the right to stop payment on an individual entry or to have entries corrected by timely notification to my financial institution. The Town of
Cave Creek also has the right to cancel this agreement for insufficient payments to my account
___________________________ ___________________________ _____________
(Print Customers Name) (Signature) (Date)
___________________________ ___________________________ _____________
(Print Customers Name) (Signature) (Date)
