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Bank Draft Authorization

Steps

1. Step One This section is complete This section is incomplete
2. Bank Information This section is complete This section is incomplete
3. Signature This section is complete This section is incomplete

Step One

BANK DRAFT AUTHORIZATION
Must be completed by the account holder.
IMPORTANT NOTE: Bank draft will begin after the account has been verified and will take at least one billing cycle to take effect. The customer will receive a bill with the notation "bank draft" once it begins. The customer will be responsible for verification of the draft. The draft will be sent to the indicated bank for payment 15 days following the "bill date" noted on the bill. If for any reason the draft needs to be canceled, this request must be submitted five (5) business days prior to the draft date. Any returned payments may result in termination of the bank draft and a service fee will be imposed in accordance with state statutes.
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Email Notice
Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public-records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
Customer’s Utility Account Number*
Please type exactly as it appears on monthly invoice
Customer's Name: *
Name on Utility and Bank Accounts must match
Phone Type*
Press the down arrow key to access the values available for this field or start typing to filter the values.
Telephone Number*
Please include area code
Email Address
Under Florida law, e-mail addresses are public records.
Service Address
Address*
Suite or Apartment Number
City*
State*
Zip*
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Bank Information

Please enter the information below very carefully. The bank can help provide this data.
Bank Name*
Bank Routing Number*
Bank Account Number*
Type of Account*
1. Checking
1. Savings
Check one
Please upload or attach a voided check, deposit form, or bank provided document for account verification.
Upload*
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Signature

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.
I the undersigned, authorize the City of Casselberry Utilities Division to send my utility bill to the above bank for direct payment form my account. I understand my account will be bank drafted every month on my posted due date. I understand that it is my responsibility to ensure payment is successfully drafted each month.
I agree. Electronic Signature*
1. I agree
Signature*
Date*
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Bank Draft Authorization

Steps

Step One

Bank Information

Signature

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