Form Center

Auto-Pay Submission Form

2. City of Anacortes - Auto Pay Application Form

4. Utility Account Number*

6. Service Address*

8. Customer Information

10. First Name*

11. Last Name*

13. Mailing Address

    Fill-in only if different from service address

15. City

    Fill-in only if different from service address

16. State

17. Zip Code

19. Daytime Phone Number*

20. Alternate Phone Number

22. Email Address

24. 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

26. Routing Number:*

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

27. Checking Account Number:*

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

29. Check Example
    

31. 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.

33. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature*

36. Date*
    Date

Leave This Blank:


38. Submit

* indicates a required field