City of Zachary

Bank Draft Authorization Form

Customer Information

Name *

Service Address *

Phone Number *

Utility Account Number *

Financial Information

Name of Bank *

Address of Bank *

Bank Account Number *

9 Digit Routing Number on Bottom Left of Check *

Request Type

Request Type *

New Bank Draft Authorization
Change to Existing Authorization
Remove Bank Draft Authorization

Bank Draft Authorization Agreement

Please note that payment is due by the due date noted on the bill. If for any reason the bank draft is returned not paid, the customer will be responsible for making payment to the City of Zachary by the due date. If payment is not received by the due date, a ten percent penalty will be assessed to the utility account. If payment is not received ten days after the due date, services will be subject to disconnection. After two returned bank drafts, the customer will be removed from bank draft and will be responsible for making payment by cash or money order.

Written notification of any changes must be received by the City of Zachary Office at least ten (10) business days prior to the effective date.

Authorization *

I authorize the City of Zachary and the financial institution listed above to initiate electronic entries into my account. This authority will remain in effect until I have cancelled it in writing.

Human Check