Office of Utilities
215 S. Broadway, Louisburg, KS 66053
913-837-5371 · louisburgkansas.gov
Auto-Draft Bill Pay Authorization
You can now save both a little time and a little money when you pay your city utility bill automatically. Auto-
Draft Bill Payment allows you to pay your utility bill by having the City deduct the total amount of your bill from
your checking or savings account at your financial institution.
You save time by not writing checks for your bill.
You save money on postage and envelopes.
With Auto-Draft Bill Payment, your monthly utility bill will be paid automatically. You will no longer have to
worry about lost payments, late payments or paying your bill while you are out of town on business or vacation.
Enrolling is easy. Simply complete the authorization form below as follows: 1) Please print clearly using ink; 2)
cut along the dotted line; 3) attach a voided check or a savings account deposit slip and 4) mail or bring to
Louisburg City Hall, 215 S. Broadway, Louisburg, KS 66053.
Your payment will be shown on the statement that you receive from your financial institution; you will still
receive your utility statement via the mail or e-billing, if you have signed up for that service. Auto-Draft Bill
Payment must be changed in writing if you change financial institutions, if you change the account number to
be debited or want to stop the service.
Auto-Draft Bill Payment is a convenient, dependable and inexpensive way to pay your utility bill. There is no
charge to enroll or to use this convenient service.
AUTHORIZATION FOR AUTO-DRAFT BILL PAYMENT
Please attach a voided check.
I authorize the City of Louisburg and the financial institution named below to deduct the amount of my monthly utility bill
from the account identified below. I understand that my Auto-Draft payment will be deducted on the due date of each bill. I
have the right to stop the deduction by notification to my financial institution at least three (3) business days prior to the
effective date. I understand if my Auto-Draft is returned for non-sufficient funds, I may be charged a fee by both my financial
institution and the City of Louisburg. My authorization and the Auto-Draft Bill Payment will remain in full force and effect
until revoked by me, my financial institution or the City of Louisburg.
Name: ______________________________________________________________ Daytime Phone: ____________________________
Property Address: (as shown on bill) ________________________________________________________________________________
Account Number:
(as shown on bill) _________________________________________________________________________________
*Financial Institution Routing Transit Number/ABA # _____ _____ _____ _____ _____ _____ _____ _____ _____
*My account number at my financial institution is: _______________________________________________________________
Signature Required: _____________________________________________________________________ Date: ___________________
(must be an authorized signer for the checking account identified above)
click to sign
signature
click to edit
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