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ACH Authorization to Draft or To Stop Draft

2. City of Forney - Utility Billing Department

   Please complete to enroll in Auto-pay with Bank Draft (ACH) or to Stop.

3. Today's Date*
5. Account Holder Name*
6. Account Number*
8. Service Address*
10. Email Address*
11. Primary Phone Number*
13. ACH election: *

    1. I wish to enroll in ACH auto-pay which will draft my bank account.
    2. I wish to discontinue ACH auto-pay and will pay with other methods.

    Please note your election to either begin or discontinue ACH draft.

15. Confirm Authorization*

    1. Authorization

    I (we) hereby request and authorize the City of Forney (The Company) to initiate entries to my checking/savings account(s) at the financial institution listed below (The Financial Institution) and, if necessary, initiate adjustments for any transactions credited in error. This authority will remain in effect until The Company is notified by me (us) in writing to cancel it in such time as to afford The Company and The Financial Institution has reasonable opportunity to act on it.

17. Name of Financial Institution *
18. Address of Financial Institution *
20. Financial Institution Routing Number*
21. Checking/Savings Account Number*
23. Online Signature *
24. Effective Date*
26. Please attach a copy of driver's license*
27. Please attach copy of a check from the account*
Leave This Blank:


29. Submit

* indicates a required field