Authorization for Automatic Payment

Authorization for Automatic Payment
I authorize the CITY OF PHARR-Utility Billing division and the financial institution names below to initiate entries to my checking/savings accounts. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution 3 days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account up to 15 days following issuance of my financial institution statement or 60 days after posting, whichever occurs first. I'm aware that if I fail to maintain an adequate bank balance on more than two instances will subject my account to be considered for removal from this automatic payment system.
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Service Address*
Water Account Number*
Signature*

Clear
Date of Signature

MonthDayYear
Date
Name of Financial Institution*
Street Address of Financial Institution*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Type*

CheckingSavings
Bank Account Number*
Financial Institution Routing Number*
Voided Check*

Please upload an image of a voided check
Cancelof
Terms & Conditions*

I agree to the terms & conditions above.
Should be Empty: