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City of Pilot Point Automatic Bank Draft Payment Authorization Form PCI

  1. I (we) hereby authorize the City of Pilot Point to initiate debit entries to my account indicated below.
  2. I authorize the City of Pilot Point Water Utility Department to:*
  3. I agree to the following:
  4. 1. I will provide the City of Pilot Point with a voided check or a bank document (a deposit slip will not be an accepted document) with my name and account information. Documents may be submitted by faxing to 940-686-4338, or drop off at City Hall, 102 E. Main St. Pilot Point, TX 76258.
  5. 2. I will be responsible for all fees resulting from uncollected payments due to non-sufficient funds, closed bank account, incorrect account number, etc.
  6. 3. I attest I am an authorized owner of the account listed below.
  7. 4. This authority is to remain in full force until I submit in writing that I wish to terminate.
  8. 5. If the automatic draft is being set up in lieu of a security deposit or to receive a 50% discount on the connect fee; then the account must stay on auto draft for at least 6 months with NO non-sufficient funds. If an NSF is received during the required 6 months the account will immediately be removed from ACH and the full deposit OR remaining connect fee will be added to the account.
  9. As it appears on billing statement.
  10. As it appears on billing statement
  11. Utility Bill Form of Delivery*
    Please choose how you would like to receive your monthly utility statement.
  12. Documentation from Financial Institution*
    Please send an official bank document that provides the banks name, the bank routing number, your name and your account number. This information can be faxed, (940) 686-4338 or emailed, [email protected] This step is required.
  13. Leave This Blank:

  14. This field is not part of the form submission.