City of Rosenberg
Customer Service Department
2110 Fourth Street
PO Box 631
Rosenberg, Texas 77471
(832)595-3400 Phone
(832)595-3402 Fax
Payment Authorization
Date ____________________
I authorize the City of Rosenberg to initiate debit entries from my _____ checking or _____ savings account indicated from the
depository below.
Financial Branch Name: ________________________________________________________________________
Financial Branch Address: _______________________________________________________________________
Transit/ABA Number - Bank Routing Number: _______________________________________________________
Bank Account Number: _________________________________________________________________________
Note: Please attach a voided check to this sheet. The payment will be drafted on the bill due date. If there are any
questions call (832)595-3400.
Utility Account Information
Account Number: _____________________________________
Account Name: _______________________________________
Service Address: ______________________________________
Phone Number: Home: _________________________________
Cell/Work: ___________________________________________
E-mail: ______________________________________________
This authorization is to remain in full force and effect until the City and Depository has received written notification from me (or either of us)
of its termination in such time and in such manner as to afford the City and Depository a reasonable opportunity to act on it.
Note: Returned bank draft payments will receive a $25.00 return fee in addition to the drafted amount. A letter will be mailed and
payment will be due 5 days after the City receives written notification from the Depository.
Customer's Signature ____________________________________
Employee's Signature ____________________________________
For office use only
Cycle _____ Route _____
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