Fillable Automatic Water/sewer Bill Payment Enrollment Form printable pdf download

Automatic Water/sewer Bill Payment Enrollment Form

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AUTOMATIC WATER/SEWER BILL PAYMENT ENROLLMENT FORM

**FORM MUST BE RECEIVED 7-10 BUSINESS DAYS PRIOR TO DUE DATE TO BE WITHDRAWN AUTOMATICALLY**

NEW ENROLLMENT

CHANGE ENROLLMENT INFORMATION

1. Complete the contact information requested below (please print):

NAME: ______________________________________________________________________

CITY OF TROY SERVICE ADDRESS:_________________________________________________

DAYTIME PHONE: _____________________________________________________________

WATER/SEWER BILL ACCOUNT NUMBER(S): _______________________________ (7 DIGITS)

____________________________________________________________________________

2. Provide your signature for authorization:

I hereby authorize the City of Troy to deduct my water/sewer bill payment from my checking or savings account

listed below. I acknowledge that the origination of ACH transactions to my account must comply with the

provisions of U.S. law. I understand that I control my payments and if at any time I decide to discontinue this

service I will submit the “Cancellation Form” directly to the City of Troy Treasurer’s Office. If the balance in my

account is not sufficient to cover the electronic payment, a $25 NSF fee will be added to my account in addition

to the late penalty and I will be terminated from the program. All information will remain confidential.

THIS FORM CANNOT BE PROCESSED WITHOUT YOUR SIGNATURE

Signature (Required): _______________________________________ Date: ____________________

Provide the required financial information below:

To ensure the correct account number is used for this electronic payment and to obtain the ABA/routing

number, please contact your financial institution for assistance.

Name of Financial Institution ___________________________________________________

ABA/Routing Number _________________________________________________________

Checking Account # ___________________________________________________________

Savings Account # ____________________________________________________________

4. Completed form MUST be sent to :

City of Troy Treasurer’s Office

500 W. Big Beaver

Troy, MI 48084

fax to: 248-524-3328

PLEASE CALL CITY OF TROY TREASURER’S OFFICE WITH ANY QUESTIONS CONCERNING THIS FORM 248.524.3333

Automatic Water/sewer Bill Payment Enrollment Form

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