Automatic Payment Plan Service (ACH) By madmin Automatic Payment Plan Service (ACH) Automatic Payment Plan Service (ACH) Authorization Agreement for Pre-authorized Payments Phone # * Driver’s License # * I (we) here by authorize the Town of Sellersburg Utilities, hereafter called “ToSU” to initiate debit entries to my (our) account indicated below and the depository named below, hereafter called “Depository”. I understand that this could take up to two billing cycles to take effect. Name of Bank/Depository * Routing Number * Account Number * Name * Signature (1) * signature keyboard Clear Second Name Signature (2) signature keyboard Clear Utility Account Number * Service Address * Service Address Service Address Service Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Name on Utility Account * This authorization is to remain in full force and effect until ToSU has received written notification form me (or either of us) of its termination in such time and in such manner to afford ToSU and Depository a reasonable opportunity to act on it. Initials * Upload a copy of a Voided Check * Drop a file here or click to upload Choose File Maximum file size: 100MB Submit
Automatic Payment Plan Service (ACH) By madmin Automatic Payment Plan Service (ACH) Automatic Payment Plan Service (ACH) Authorization Agreement for Pre-authorized Payments Phone # * Driver’s License # * I (we) here by authorize the Town of Sellersburg Utilities, hereafter called “ToSU” to initiate debit entries to my (our) account indicated below and the depository named below, hereafter called “Depository”. I understand that this could take up to two billing cycles to take effect. Name of Bank/Depository * Routing Number * Account Number * Name * Signature (1) * signature keyboard Clear Second Name Signature (2) signature keyboard Clear Utility Account Number * Service Address * Service Address Service Address Service Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Name on Utility Account * This authorization is to remain in full force and effect until ToSU has received written notification form me (or either of us) of its termination in such time and in such manner to afford ToSU and Depository a reasonable opportunity to act on it. Initials * Upload a copy of a Voided Check * Drop a file here or click to upload Choose File Maximum file size: 100MB Submit
