Utility Billing Direct Payment Form
265 Strand St, St. Helens, OR 97051 | 503-397-6272 | www.sthelensoregon.gov
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Completion of this form authorizes regularly scheduled payments to be made from your checking or savings account.
Your payments will be made automatically on the payment due date specified on your utility statement. Proof of
payment will appear with your following utility statement. The City of St. Helens reserves the right to deny or cancel
participation in the Direct Debit plan. Your participation in this plan will remain in effect until the City receives
notification in writing to cancel future payments.
Forms can be mailed to the address above or emailed to the Utility Billing Office. Direct emails can be found on the city’s
website under Departments > Utilities
Customer Name: ___________________________________ Account Number: __________________________
Service Address: ___________________________________
Financial Institution: ________________________________ Institution Phone: __________________________
Name(s) on Account: ________________________________
Routing Number: __________________________ Account Number: __________________________
What Type of Account: Checking Account: ______ Savings Account: ______
Authorized Signature: _________________________________________ Date: _______________________
Authorized Signature __________________________________________ Date: _______________________
STAFF USE ONLY
Received By: ______________________________ Entered Date: ___________________
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