Fillable City of Tualatin EASY PAY APPLICATION 18880 SW (City of Tualatin)

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City of Tualatin EASY PAY APPLICATION 18880 SW (City of Tualatin)

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City of Tualatin
18880 SW Martinazzi Avenue
Phone: (503) 691-3056
billing@tualatin.gov
EASY PAY APPLICATION
ACH payment enrollment
N
ame
CUSTOME
R
Utility Account Number:
Service Address
AUTHORIZATION AGREEMENT
I/we hereby authorize the City of Tualatin to initiate debit entries to the bank account indicated below and the
financial institution listed below to transfer payment, for and in the amount of my utility bill.
Financial Institution:
9 digit Routing Number
Bank Account Number
Account Type (select one)
Checking
Savings
This authorization is to remain in full force and effect until the City of Tualatin has received written
notification from the customer to terminate ACH transactions. It may take up to one month for changes to
become effective. Please continue paying your bill until your bill indicates: "Bank Draft - Do Not Pay"
Signature: Date:
N
ame on Bank Account
Please include a voided check with your application form.
Send your completed application form with voided check to: City of Tualatin
Utility Billing
18880 SW Martinazzi Avenue
Tualatin, OR 97062
Prenote Date 1st Debit Date Entered in SB
FOR OFFICE USE ONLY
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City of Tualatin EASY PAY APPLICATION 18880 SW (City of Tualatin)

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Completed 16 July 2020

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