City of Oakwood - Request for Automatic Payment of Utility Bills

I authorize the City of Oakwood to withdraw funds from the bank account listed below to automatically pay my Oakwood utility bill each month. I will receive a copy of my monthly utility bill prior to the withdrawal, and I can cancel this automatic payment at any time by providing a written notification to the City three (3) business days prior to the cancellation. This authority will remain in effect until I notify the City, in writing, to cancel my automatic payment.

Utility Account Customer Information:

Customer Name:

Service Address:

Telephone Number:

Banking Information:

Financial Institution:

Account Name:

ABA / Routing #:

Account #:

Checking

Savings

Signed:

Date: