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Auto-Pay Submission Form

2. City of Anacortes - Auto Pay Application Form

4. *DO NOT FILL THIS OUT IF YOU HAVE ALREADY SIGNED UP THROUGH ANOTHER FORM OF PAYMENT USING YOUR BANK OR PAYMENTUS, PLEASE*

6. Utility Account Number*

8. Service Address*

10. Customer Information

12. First Name*

13. Last Name*

15. Mailing Address

    Fill-in only if different from service address

17. City

    Fill-in only if different from service address

18. State

19. Zip Code

21. Daytime Phone Number*

22. Alternate Phone Number

24. Email Address

26. 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

28. Routing Number:*

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

29. Checking Account Number:*

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

31. Check Example
    

33. 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.

35. 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.
37. Electronic Signature*

38. Date*
    Date

Leave This Blank:


40. Submit

* indicates a required field