Amherst Municipal Utilities Form printable pdf download

Amherst Municipal Utilities Form

Amherst Municipal Utilities

480 Park Avenue

P.O. Box 470

Amherst, OH 44001-0470

Phone: (440) 988-4224 Fax: (440) 988-3118

Automated Bill Payment Enrollment for Amherst Municipal Utilities

Name (as shown on your bill) __________________________________________

Account Number ____________________________________________________

Service Address _____________________________________________________

Daytime Phone # _____________________________________________________

PLEASE NOTE:

The bill you receive next month will have an annotation on the left side stating

“PAY THIS BILL”. All accounts must be “Pre-Noted” NO EXCEPTIONS as

of 2-21-2012

Your account will be debited on the 10

of each month. If the 10

falls on a

Saturday, Sunday or holiday, your account will be debited the next banking

business day. If there are any changes in your banking information, you must

notify the utilities office immediately. Debits are transmitted to the bank 3 days

prior to the actual deduction. After transmission to the bank changes cannot be

made.

Please deduct my Automated Bill Payment from my account:

Financial Institution Name (Please print) _________________________________

Account at Financial Institution _________________________________________

Financial Institution Routing/Transit Number _____________________________

Financial Institution City and State ______________________________________

I authorize Amherst Municipal Utilities to deduct my utilities payment from the

account listed above. I understand that if I decide to discontinue the payment plan,

I will notify Amherst Municipal Utilities by going into the Utilities Office located at

480 Park Avenue to sign the discontinuance form.

Signature _________________________

PLEASE KEEP A COPY OF THIS AUTHORIZATION FOR YOU RECORDS

A check that is marked “VOID” must be attached to this form for verification of all

financial institution information.

Amherst Municipal Utilities Form