rev06‐07‐2018
AUTOMATIC UTILITY PAYMENT PROGRAM
YES! I would like to enjoy the convenience of enrolling in a free Automatic Utility
Payment Program – *note this is for the property owner only, tenants are not eligible.
To enroll simply:
1. Please fill out the account information at the bottom of this page for the account
from which you want your Utility payment to be withdrawn whether for checking,
savings, or money market accounts.
2. Sign this form and mail it thirty (30) days prior to the next Utility due date to:
Town of Essex
Attn: Finance
81 Main Street
Essex Jct, VT 05452
OR – email it to utilitybilling@essex.org
I authorize the Town of Essex / Village of Essex Junction to instruct my financial institution
to deduct my utility payments directly from my account. The automatic payment amount,
frequency and transaction date will correspond as disclosed on each utility bill that is
provided to me. If at any time I wish to discontinue the service, I will simply notify the Town
/ Village in writing, within 15 days of my next scheduled payment.
____________________________________ __________________________
Your Signature Date (mm/dd/yyyy)
____________________________________ __________________________
Property Location Utility Account Number
ACCOUNT INFORMATION: Checking Account Savings Account
____________________________________________
Your Name (Please print)
____________________________________ __________________________
Your email address Daytime Telephone Number
(We will send you a confirmation email when we have received your information)
_____________________________________________________________________
Your Mailing Address
____________________________________ __________________________
Your Banks Name Bank Account Number
____________________________________
Bank Routing Number
click to sign
signature
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