Authorization For Pre-Authorized Payments
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1CITY OF ROBERTSDALE
AUTHORIZATION FOR PRE-AUTHORIZED PAYMENTS
I (we) authorize the CITY OF ROBERTSDALE, hereinafter called the CITY, to initiate debit entries and to
initiate, if necessary, credit adjustments for any debit entries in error to my (our) ___checking account
___savings account (select one) indicated below and the depository named below, hereinafter called
DEPOSITORY, to debit and/or credit the same to such account.
BANK
DEPOSITORY NAME________________________________________BRANCH___________________
CITY_______________________________________STATE____________ZIP_____________________
TRANSIT/ABA#_______________________________ACCOUNT#______________________________
I (we) certify that my (our) signature below is that of an authorized signer(s) and responsible party (ies) on
the account to be credited or debited as a result of the authorization and further agree to indemnify and hold
harmless the DEPOSITORY, the CITY, any financial institution originating the credit or debit and any
other entity from any damage, loss, or cost incurred as a result of any unauthorized signature on this
authorization.
This authority is to remain in full force and effect until the CITY 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 a reasonable
opportunity to act on it.
I (we) further understand that the adjustment will be made to my (our) account listed above on the tenth of
each month, in the amount owed on my (our) utility account listed below.
UTILITY
NAME_____________________________________________________ACCOUNT#________________
SIGNATURE_______________________________________________DATE______________________
Please attach a voided check if a checking account is selected.
FOR CITY USE ONLY
Date Received________________________________
Processed By____________________________
First Month Adjustment to be made_________________________________________________________
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