Automatic Debit Authorization

Automatic Debit Authorization Form

Bank Draft Auto-Pay
Name *

First Name Last Name
CID - Account # *
XXXXXX-XXXXXX
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Last 4 of SSN or Tax ID *
Email *
example@example.com
Phone # *
Bank Draft *

Checking Account Savings Account
PLEASE NOTE:

Automatic bank drafts can only be authorized using a checking account. Saving accounts are not permitted for bank drafts.

CHECKING ONLY
Financial Institution *
Bank Name
Bank Information *

Routing Number Bank Account Number
Please supply a copy of a voided check. You can either: *

Take a photo Upload a copy
Take Photo *
File Upload *

Please include a scanned image of a voided check or bank authorization letter
Cancel of
Terms & Conditions

Please Read
By submitting this form, you agree to all terms and conditions *

I understand I will continue to make payments as usual until my bill states, “BANK DRAFT – DO NOT PAY” or “PAID BY DRAFT – DO NOT PAY.” Failure to do so will result in late fees or interruption of service. I authorize the City of Round Rock to debit the account indicated above to pay my monthly utility bill. I understand that my bank account will be debited for the total amount due on the due date. (Should the due date fall on a weekend or holiday, the draft will occur on the business date after the due date.) However, suppose the City of Round Rock erroneously debited funds from the above account. In that case, I authorize the City of Round Rock to initiate the necessary credit entries not to exceed the total amount of the entry in question. I understand this authorization will remain in effect until the City of Round Rock has received written approval to terminate automatic debit. The customer is responsible for notifying the City of Round Rock, in writing, of any changes to their bank account at least five business days before being charged on the due date. In addition, a $25.00 service fee will be charged for any debits returned unpaid due to insufficient funds, closed accounts, etc.
Customer Signature *
Should be Empty:

Automatic Debit Authorization Form

Terms & Conditions