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2. DAVE LOWERY

   ^MAYOR

   CHRIS LIGHTFOOT

   ^{INTERIM CITY MANAGER} 

   AMY MYERS

   ^{CITY ATTORNEY}

3. 

4. COMMISSIONERS 

   SAM PEEBLES 

   PAT PERNO 

   JAMIE WARRICK 

   JUDY TINDER

6. EFT CHANGE FORM

   Each month you can enjoy the privilege of having your bank, savings and loan, or credit union deduct your City of Lynn Haven utility bill directly from your checking account. 

   Please allow approximately 3 to 6 weeks for your draft enrollment to be complete. Time frame varies depending on account status in an active bill run.  Bills that are currently due or are being generated will need to be paid manually. To intercept your draft at any time, you must make a manual payment 7 business days before your scheduled draft date. To un-enroll in EFT, you must complete the EFT Stop Form and allow 3-6 weeks for the un-enrollment to be complete. NSF fees are applied to all returned transactions.

8. Account Owner's Name*
10. Service Address*
12. Account Number*
13. Account Number (if Multiple)
15. Phone Number*
16. E-Mail Address*
18. Previous Financial Institution*
19. New Financial Institution*
21. Previous Checking Account Number*
22. New Checking Account Number*
24. Previous Routing Number*
25. New Routing Number*
27. Enroll in Paperless Billing?*

    1. Yes
    2. No
29. Voided Check or Bank Authorization Letter*
30. Drivers License*
32. Agreement

    I HAVE READ AND UNDERSTAND THAT BY SIGNING BELOW, I AGREE TO THE FOLLOWING:

    
    

    I authorize the above named financial institution to charge my checking account the amount of any City of Lynn Haven utility bill and to make the deduction payable to the order of the City of Lynn Haven. In making this authorization, I agree that each payment shall be the same as if it were an instrument personally signed by me. I understand that the draft date shall be at least 15 days after the billing date. This authority is to remain in effect until revoked by either of the undersigned in writing with a 21-day notice, or until the referenced utility account is closed. I also understand that both the financial institution and the City of Lynn Haven reserve the right to terminate this payment plan (or my participation within) at any time.

    You will continue to receive a bill each month for information purposes. This will allow you the opportunity to review your charges and still have time to call the City should you have any questions prior to your account being drafted. The City will automatically transfer funds from your checking account at least 15 days after the current statement date. In order for this system to work properly, your utility account must meet program requirements and payments be current at the time you begin participation.

    Draft items returned by your bank as unpaid due to insufficient funds, account closed, etc., will be treated as a returned check. A service charge will be assessed and failure to make payment could result in your utility service being disconnected. The draft will remain in effect until revoked in writing with a minimum 21-day notice or until the utility account is closed.

    
    

    Please allow approximately 3 to 6 weeks for your updated draft enrollment to be complete. NSF fees are applied to all returned transactions. To avoid your charges drafting your prior checking account during this time, please manually pay your bill at least 7 days before your scheduled draft date.

34. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
36. Electronic Signature*
37. Date:*
    Date:
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field