Fillable DIR-PAY-1 Authorization For Direct Payment Of Utilities[1] AUTHORIZATION FOR DIRECT PAYMENT PROGRAM

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DIR-PAY-1 Authorization For Direct Payment Of Utilities[1] AUTHORIZATION FOR DIRECT PAYMENT PROGRAM

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AUTHORIZATION FOR DIRECT PAYMENT PROGRAM
SAVE YOUR TIME AND MONEY
Sign up now for the City of Lacey's Utility Direct Payment Program.
The City of Lacey now offers customers a convenient way to pay utility
bills without the hassle of writing and mailing checks. Simply fill out
this form, authorizing your bank or financial institution to have your City
of Lacey utility bill deducted automatically from your checking account
on the date date. Include a voided check when you return your form,
along with your current utility payment, and let this be the last things
you mail back to us.
Authorization for Direct Payment Program
Name: ________________________________________________________________
Service Address: _____________________________________________________
_______________________________________________________________________
Utility Account Number: _____________________________________________
Financial Institution: ________________________________________________
Checking Account Number: __________________________________________
Daytime Phone Number: _____________________________________________
Co-Applicants Name: _________________________________________________
Applicant Signature: _________________________________________________
Co-Applicant Signature: ______________________________________________
(Optional) Please send my bill electronically to my email instead of a
paper copy, email address:___________________________________________
I (we) hereby authorize the City of Lacey to automatically withdraw the total amount
due on my (our) utility billing statement from my (our) checking account. I (we)
authorize the financial institution named here to accept such transactions initiated by
the City of Lacey. The withdrawals shall be made from my (our) checking account on
the due date printed on the utility statement. This authorization will remain in effect
until I (we) have notified the City of Lacey that I (we) no longer with to participate.
PLEASE ATTACH YOUR VOIDED CHECK- WE CANNOT PROCESS
YOUR APPLICATION WITHOUT IT.
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DIR-PAY-1 Authorization For Direct Payment Of Utilities1 AUTHORIZATION FOR DIRECT PAYMENT PROGRAM

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Completed 13 July 2020

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