Utility Billing Surepay Sign-up Form
Customer Name __________________________________ Utility Account # or Cust # _________________________
Daytime Phone # _________________________________ Donate $1.00 to Scottsdale Cares Yes No
Service Address _____________________________________________________________________________
Surepay (Checking or Savings Account) You are required to check mark one of the boxes below.
New application
Continue to pay your bill until “Do not Pay…” appears on the bottom portion of your statement.
Change existing application
Immediately – your current bill will not be processed with your Checking or Savings Account
information. You are responsible for paying your current and future bills by the due date via another
payment method i.e., mailing in payment, paying online etc, until your bill states “Do not Pay…” on the
bottom portion of your statement.
After current payment is processed with your Checking or Savings Account information we have on
file. You are responsible for paying your future bills by the due date via another payment method i.e.,
mailing in payment, paying online etc, until your bill states “Do not Pay …” on the bottom portion of
your statement.
Cancel existing application
Immediately- your current bill will not be processed with your Checking or Savings Account
information. You are responsible for paying your current and future bills by the due date via another
payment method i.e., mailing in payment, paying online etc.
After current payment is processed with your Checking or Savings Account information we have on
file. You are responsible for paying your future bills by the due date via another payment method i.e.,
mailing in payment, paying online etc.
Required information:
New Checking: Attach a voided check or letter from the bank reflecting the Account and Routing numbers.
New Savings: Attach a deposit slip or a letter from the bank reflecting the Account and Routing numbers.
Note: Due to banking regulations when submitting a new application or changing your Checking or Savings
Account information, please continue to pay your bill until it states “Do not pay …”on the bottom portion of
your statement. Be aware it may take up to two billing periods for your payment to be automatically debited
from your Checking or Savings Account. When submitting a new application or changing your existing
application, it could take up to 8 days to process your request.
The charge against your Checking or Saving Account will occur on or after the due date shown on your monthly statement.
Any changes to the Checking or Savings Account information MUST be reported to the City of Scottsdale immediately.
Failure to do so may result in the discontinuance of the automatic payment plan.
I understand in order to provide sufficient time to change, cancel or stop a payment through the automatic payment plan; I
must notify the City of Scottsdale no less than 8 days prior to the date shown on my billing statement. Notification must be
made in writing and sent to the City of Scottsdale using the address information or fax number below.
City of Scottsdale 7447 E. Indian School Rd Suite 215 Fax: 480-312-4805 payments@scottsdaleaz.gov
Scottsdale AZ 85251 Phone: 480-312-7400
I understand that to remain on the automatic payment plan, I must maintain sufficient funds in my designated account. I
have selected above whether I will participate monthly in the Scottsdale Cares donation program. To learn more about the
Scottsdale Cares donation program visit: http://www.scottsdaleaz.gov/assistance/scotcares.asp
. I understand that if I did not
specify an option the utility account will be set up as NOT donating.
I hereby authorize and request the City of Scottsdale, unless otherwise instructed by the undersigned, to charge for the
service address above all utility fees rendered on the Utility Statement.
Print Name _______________________ Signature__________________________ Date__________
click to sign
signature
click to edit
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