Form Center

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 STOP FORM

   
   

   Please allow approximately 3 to 6 weeks for your draft removal 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. 

8. Account Owner's Name*
10. Service Address*
12. Utility Account Number*
13. Utility Account Number (if Multiple)
15. Phone Number*
16. E-Mail Address*
18. Financial Institution*
19. Checking Account Number to remove*
21. Drivers License*
23. Agreement

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

    
    

    I understand it may take anywhere from 3-6 weeks to stop this draft process. To avoid any further transactions from drafting the account listed above, please submit a manual payment no less than 7 days prior to your scheduled draft date.

    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.

25. 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.
27. Electronic Signature*
28. Date:*
    Date:
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field