Fillable CITY OF DAHLONEGA BANK DRAFT REQUEST FORM Writable

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CITY OF DAHLONEGA BANK DRAFT REQUEST FORM Writable

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The CITY OF DAHLONEGA BANK DRAFT REQUEST FORM Writable form is 1 page long and contains:

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File type: PDF

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BROWSE CITY OF DAHLONEGA (GA) FORMS

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PLEASE MAIL OR DROP OFF THE COMPLETED FORM AND A VOIDED ORIGINAL CHECK FROM YOUR BANK ACCOUNT.
CITY OF DAHLONEGA
465 RILEY ROAD
DAHLONEGA, GA 30533
UTILITY BILLING ACH BANK DRAFT REQUEST FORM
UTILITY ACCOUNT INFORMATION:
ACCOUNT NAME
ACCOUNT NUMBER
SERVICE ADDRESS
MAILING ADDRESS
PHONE NUMBER
BANK ACCOUNT INFORMATION:
BANK NAME
ROUTING NUMBER
BANK ACCOUNT NUMBER
TYPE OF ACCOUNT
CHECKING
SAVINGS
MONTH FOR DRAFT TO BEGIN
I HEREBY AUTHORIZE THE CITY OF DAHLONEGA TO DEBIT MY ACCOUNT AUTOMATICALLY FOR PAYMENT OF MY
MONTHLY PUBLIC UTILITIES BILL. THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL I NOTIFY THE CITY IN
WRITING THAT I NO LONGER DESIRE THIS SERVICE, ALLOWING THE CITY REASONABLE TIME TO ACT ON MY
NOTIFICATION. THE DRAFT WILL BEGIN WITH THE BILL DUE DATE FOLLOWING THE SET UP.
I UNDERSTAND THAT THE CITY WILL CONTINUE TO SEND ME A MONTHLY BILL AND THAT MY BANK ACCOUNT WILL
BE DRAFTED FOR THE TOTAL AMOUNT DUE ON THE ACCOUNT AS OF THE DUE DATE. I FURTHER UNDERSTAND
THAT THE CITY MAY IMPOSE A PROCESSING FEE IF THERE ARE INSUFFICIENT BANK FUNDS ON THE DAY OF THE
DRAFT. I ALSO UNDERSTAND THAT IF MY DRAFT IS RETURNED UNPAID, MY DRAFT SERVICE WILL BE
DISCONTINUED.
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CITY OF DAHLONEGA BANK DRAFT REQUEST FORM Writable

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Completed 12 July 2020

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