Authorization Form |
| | |
A Direct Payment Program from
City of Effingham
Water & Sewer Department | | |
I (we) hereby authorize the City of Effingham, to make debit entries to my (our) account indicated below. I (we) acknowledge the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. This authority is to remain in full force and effect until the City of Effingham has received written notification from me (or either of us) of its termination in such time and manner as to afford City of Effingham and Effingham State Bank a reasonable opportunity to act on it.
|
| Name (Please Print): | Account Number | | | | |
|
|
|
| Select One of the following |  | New Authorization |  | Change in account information | |
|
| Authorized Signature(s) for Account Listed below: |
|
|
| Please take payment directly from my | | Checking Account (attach voided check) | | Savings Account
(deposit slip attached) | |
|
|
|
| Financial Institution Name: | Financial Institution Phone No.: | |
|
|
City of Effingham Water & Sewer Department
201 E. Jefferson
Effingham, IL 62401
217.342.2366 |
