Dear Sir or Madam:
We will soon be offering automatic bank withdrawals for payment of your water, sewer & solid waste account. Simply fill out the form below and return with your payment. You will still receive your postcard every quarter from us stating the amount that will be withdrawn out of your account on the 20th of the month when payment is due. You will notice that on the postcard it will clearly state BANK CUSTOMERS DO NOT PAY. If you have further questions please feel free to contact our office at (563) 744-3475
City of Farley
Utility Department
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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
I (We) hereby authorize the City of FARLEY
To initiate debit entries to my (our)
________ Checking or ________ Savings
Account indicated below and the depository named below.
Depository (Bank) Name __________________________________________________
City ____________________________ State _____ Zip Code ____________________
Bank Routing No. ___________________________ Account No. _________________
This authorization to remain in full force and effect until
City and Depository has received written notification
from me (or either of us) of its termination.
Name(s) __________________________________ City Account No. ______________
Date _______ / _______ / _______
Signature ______________________________________________________________
~ ~Please attach a voided check or deposit slip along with this form~ ~