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Auto-Pay Submission Form

2. City of Anacortes - Auto Pay Application Form

4. Utility Account Number*

6. Service Address*

8. City*

9. State*

10. Zip Code*

12. Customer Information

14. First Name*

15. Last Name*

17. Mailing Address

    Fill-in only if different from service address

19. City

    Fill-in only if different from service address

20. State

21. Zip Code

23. Daytime Phone Number*

24. Alternate Phone Number

26. Email Address

28. Please Enter Checking Account Information Here:

    "Auto-Pay" will show on your next billing in the "amount enclosed" area

    "Auto-Pay" will show on your next billing in the "amount enclosed" area

30. Routing Number:*

    Enter the 9 digits that appear at the bottom left of your check (109800033 in the example)

31. Checking Account Number:*

    Enter your account number (333562222 in the example). Do not include the check number (3333 in the example).

33. Check Example

    

35. Agreement and Signature

    By submitting this application, I authorize the City of Anacortes to withdraw from my account the total amount due on my billing statement on the due date indicated. I understand that if the account does not have sufficient fund to cover the withdrawal there will be a returned bank item fee charged to my utility account. Withdrawals will continue until I request that the City of Anacortes cancel Auto-Pay. Any payment in process at the time I cancel may still be deducted from this account.

    By submitting this application, I authorize the City of Anacortes to withdraw from my account the total amount due on my billing statement on the due date indicated. I understand that if the account does not have sufficient fund to cover the withdrawal there will be a returned bank item fee charged to my utility account. Withdrawals will continue until I request that the City of Anacortes cancel Auto-Pay. Any payment in process at the time I cancel may still be deducted from this account.

37. E-Signature*

38. Date*
    Date

Leave This Blank:


39. Submit

* indicates a required field