City of Bremerton - Utility Billing
345 6th Street, Suite 100 • Bremerton, WA 98337-1891
(360) 473-5316 • FAX (360) 473-2330 • billing@ci.bremerton.wa.us
AUTOMATIC PAYMENT AUTHORIZATION
Utility Billing Account #
I hereby authorize the City of Bremerton to automatically withdraw from the checking account identified on the
enclosed copy of a voided check, the amount due for charges on my utility billing account. This authorization
shall continue in effect until a written notice of cancellation is received by the Utility Billing office. I understand it is
my responsibility to notify the City of Bremerton if I change my account or change banks, by submitting new
paperwork.
(Please Print) Name
Service Location
Phone Number
Signature
Date
FOR BILLING OFFICE USE ONLY
NEW / CHANGE / CANCEL
Account #
Name
Service Address
Closed Date
Comments Initial
06/19 KD
Date ProcessedDate Rec'd
(Enter your 7-digit account number without dashes, i.e. 1234567)
New Change
Cancel
Cell
WorkHome
Email Address
BankBill Class
Tenant
Owner
