ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION FORM
Please check one: New EFT Participant Current participant with changes
CITY UTILITIES ACCOUNT INFORMATION
All accounts on this form must be paid from the same bank account. If you would like alternate utility
accounts deducted from different accounts, please complete a separate EFT form for each account.
FINANCIAL INSTITUTION ACCOUNT INFORMATION
Owner of Account at Financial Institution:
Name of Financial Institution: _____________________________ Branch:
Financial Institution Phone Number: _______________________
Routing Number (9 digits): ________________________ Account Number:
Please check one: Checking Account Savings Account
AUTHORIZATION AGREEMENT
I hereby authorize the City of Osage Beach Water and/or Sewer utility to initiate withdrawals from my
Financial Institution indicated above for payment of my monthly utility bill. I further authorize the bank or financial
institution named above to debit such account. I understand the debit will be made on the due date of each
monthly bill for the balance amount. This authorization is to remain effective until the City of Osage Beach or the
Financial Institution has received written notification from me of its termination. Notice should be received in time
and in such a manner as to afford the City of Osage Beach or the Financial Institution a reasonable opportunity
to act on it. The City of Osage Beach reserves the right to void this agreement at any time without prior notice.
I understand that a return fee will be applied to any returned items.
Signature of Bank Account Owner: _______________________ ___ Date:
Address:
Phone Number: Day: _________________ ___ Evening:
PLEASE ATTACH A VOIDED CHECK OR A SAVINGS DEPOSIT SLIP TO THIS DOCUMENT
C
ity of Osage Beach
1000 City Parkway
Osage Beach, MO 65065
Ph
one: (573)302-2000 • Fax (573) 302-2039
