*N/A for Civil Service or if not on City of Plano Health Plan*
AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)
City of Plano, Texas
The City of Plano Accounting Department offers retirees an option to pay their monthly health insurance
premium to the City via automatic bank draft. If you are a new retiree, submit a check payment for
one month along with this Authorization Agreement which will be used to pay your next premium
until the automatic draft starts the month following. (This allows ample time for the City to conduct
necessary testing that ensures your first draft will be successful.)
Please read the following information and instructions carefully before you sign up for automatic bank
draft. Be certain you understand the terms, conditions and time frames involved in the process.
Should you have any questions, please contact City of Plano Accounting, 972-941-5213.
If you choose this payment option, your account will be automatically debited by the amount of your
premium. Drafts will occur on the first banking day of the month. Be sure you have funds available to
cover the draft from the account used. If a draft comes back “insufficient funds,” your payment still must
be in Accounting by the 5
th
of the month. You may need to deliver your payment to avoid late fees.
The draft will be debited from a single account. If you wish to use a s
avings account,
please
be
sure
the
account
a
nd the routi
ng
numbers
ar
e correc
tly
and
c
learly
print
ed
on this
f
orm.
--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- save above section for your records --- --- --- --- --- --- --- --- --- --- --- ---
I (we) hereby authorize the City of Plano to initiate debit entries to my (our) ____Checking Account /
____Savings Account (select one), indicated at the financial institution named below and to debit funds
from this account. I (we) acknowledge that the origination of the ACH transactions to my (our) account
must comply with the provisions of the U.S. law.
City: State:
Zip:
Account Number:
Routing Number:
This authorization is to remain in full force and effect until the City of Plano Accounting Department has
received written notification for me (or either of us) of its termination in such time and manner as to give
the City of Plano Accounting Department a reasonable opportunity to act on it.
Name:
Date:
Signature:
(Please Print)
Employee ID#:
Bank Name:
Branch:
Revised 1-2020
