ACH Recurring Payment Authorization Form
Account Number (from your utility bill):
Name:
Address:
Mailing Address (if different):
E-mail Address:
Phone Number:
Account Type (checking or savings):
Name on Account:
Name of Bank:
Bank Routing #:
Bank Account Number:
Bank City and State:
Signature:
Date:
Message:
Please Attach an image/copy of your check or savings account deposit slip
Attachment:
Terms and Conditions: I authorize the City of New Haven to debit the bank account indicated on this form on the 20th of each month for payment of my obligations. I understand and agree that any and all changes in my account information, including requests to terminate this agreement, must be in writing and be delivered to the City of New Haven, at least 21 days prior to the next due date. If the payment falls on a weekend or holiday, I understand and agree that the payment may be executed on the next business day. I understand and agree that as this is an electronic transaction, adequate funds must be available for withdrawal from my account by the payment due date. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF), submission error or other bank related return reasons, I understand and agree that the City of New Haven will not resubmit the ACH debit transaction and I understand and agree that a $25.00 fee will be added to my account. Payment will be required in cash for the rejected amount plus the $25.00 fee. I acknowledge that the origination of ACH transactions to my account comply with provisions of the U.S. law and agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Code:
