Automatic Utility Payment Plan Agreement Authorization For Direct Deposits/payments (Ach Debits/credits) Form - City Of Richmond, Department Of Public Utilities

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AUTOMATIC UTILITY PAYMENT PLAN AGREEMENT AUTHORIZATION FOR
DIRECT DEPOSITS/PAYMENTS (ACH DEBITS/CREDITS)
Company/
Individual
Name ________________________________________ Phone Number ________________
I (we) hereby authorize the City of Richmond, Department of Public Utilities, hereinafter called DPU, to
initiate debit/credit entries to my (our) checking account indicated on the attached voided check at the
depository financial institution named on such document, hereinafter called DEPOSITORY, and to
debit/credit the same to such account. I (we) acknowledge that the origination of ACH transactions to my
(our) account must comply with the provisions of U.S. law.
This authorization is to remain in full force and effect until DPU has received written notification (signed by
all names on bank account) of its termination in such time and in such manner as to afford DPU and
DEPOSITORY a reasonable opportunity to act on it.
List of DPU Account Number (s) _______________________ _______________________
__________________________ _________________________ ________________________
OR Check here for all accounts for this customer
(Please attach list of accounts if more space is needed.)
ATTACH VOIDED CHECK
*Dollar limit if desired $________________
(all names on bank account need to sign below )
Print Name _______________________ Signature _______________________ Date _____
Print Name _______________________ Signature _______________________ Date _____
NOTE: ALL WRITTEN DEBIT/CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE
RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR
IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
*If charges exceed dollar limit specified, the customer will be required to pay entire bill manually (cash or
check). A payment that is over the limit can’t be processed electronically.
DPU USE ONLY:
Entered By ___________________________________ Date ___________________________
Customer Number _____________________ Cycle # ____ Bank Name __________________
Routing # ____________________ Bank Acct # _____________________ Bank # _________
Cancellation Entered By ________________________________________ Date ___________

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