Fillable Billing and Collections Division Bank Draft Authorization (City of Fayetteville)

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Billing and Collections Division Bank Draft Authorization (City of Fayetteville)

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File type: PDF

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Billing and Collections Division
Bank Draft Authorization
Utility Account No._______________________Sequence #__________________
Customer Name____________________________________________________
Serv
ice Address____________________________________________________
City____________________________, State_______________Zip___________
Home Phone_______________________Cell Phone_______________________
Bank Name________________________________________________________
Bank Address______________________________________________________
City____________________________, State_______________Zip___________
Checking Account No._______________________________________________
Bank Draft Authorization
I hereby authorize the City of Fayetteville to bank draft my checking account for payment
of my monthly water/sewer/sanitation bills. I understand this authority shall remain in full
force and effect until written notification of termination is received from me and the City of
Fayetteville has a reasonable opportunity to process my cancellation request. I
understand that nothing contained in this Authorization shall serve to reduce my
obligation to pay my City of Fayetteville utility bill and that services may be disconnected
should I fail to have sufficient funds in my designated account to cover the amount of the
bill. Should my draft be dishonored by my financial institution the City of Fayetteville will
no longer allow me to have drafts. I further understand that the name on the bank account
to be drafted is the name that appears on the City of Fayetteville utility account. The
attached voided check represents the account that is to be drafted.
Date__________________Signed_________________________________________________
(Attach voided check here)
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Billing and Collections Division Bank Draft Authorization (City of Fayetteville)

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Completed 21 January 2021

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