COMPLETE THIS FORM
TO AUTHORIZE ELECTRONIC PAYMENTS AND/OR PAPERLESS BILLING
Account No. ____________________________________ Email Address ________________________________
Name ____________________________________________________ Telephone _________________________
Service Address ______________________________________________________________________________
Financial Institution Information
Name of Bank_______________________________________________________Checking ___ Other ___
Routing No. ______________________________________Account No. ________________________________
ATTACH A VOIDED CHECK. IF YOU DO NOT HAVE ONE, REQUEST FROM YOUR BANK A DIRECT DEBIT
FORM TO VERIFY YOUR ACCOUNT.
SELECT ONE OR BOTH OPTIONS BELOW BY SIGNING AND DATING THE AUTHORIZATION(S):
Automatic Utility Bill Payment Authorization
I hereby authorize the City of Mt. Shasta (City) to electronically receive payments for my utility bill directly from
my bank account. I understand that I will continue to receive my utility bill each month and that on the third
Wednesday of the month my bank account will be debited for the total amount due. I further understand that if
I have a dispute with my bill, I must notify the City at least seven (7) days prior to the third Wednesday of the
month in order to stop this automatic payment. I understand I must have the necessary funds available in my
bank account on the withdrawal date or the City will assess a non-sufficient funds (NSF) fee and require manual
payment for the non-sufficient funds. I realize that two (2) NSF situations within a twelve-month period may lead
to the termination of my automatic payment. This authorization will be in effect until my account and/or the
automatic payment program is terminated by the City, or until I have given the City notice to cancel this
agreement. The City reserves the right to terminate this program at any time.
Signature ______________________________________________ Date_________________________________
Paperless Billing Authorization
I hereby authorize the City of Mt Shasta (City) to send my utility bill electronically by email provided above. I
understand the City is not responsible for undeliverable emails. I further understand I am required to submit
payments by the utility bill due date regardless if an email is received or not. Past due fees will not be waived if
an email is not received. It is my responsibility to ensure payment is made in the absence of a bill.
Signature ______________________________________________ Date ________________________________
Completed forms must be received by the 20
th
of the month in order to have automatic utility payment or
paperless billing become effective the following month.
FOR OFFICE USE ONLY:
Date Received: _________________________________________ Work Order #: _________________________
