Section 1 of 1 in this document

City of Pocatello Customer Bank Draft Form

Customer

Customer Name

Customer Phone Number

Customer Email Address

Bank Draft

Bank Draft Action

Authorize

Modify

Cancel

Bank Account Type

Checking Account

Savings Account

IMPORTANT: You must include a VOIDED CHECK or PROOF OF ROUTING AND CHECKING ACCOUNT NUMBERS front your bank including your name, bank name, routing number, and checking account number so that this request can be processed.

Voided Check (or Proof of Routing and Account Numbers)

Authorization

Statement of Authorization

I hereby authorize the City of Pocatello Finance Department to draft my bank account monthly for the amount of services billed by the City of Pocatello Finance Department. I authorize the financial institution listed on the attached voided check or proof of account ownership to debit such amounts from my account as indicated below.

Cancellation

Cancellation Request

I hereby request the City of Pocatello Finance Department to discontinue drafts of my bank account as a method of payment. I acknowledge that I am responsible to remit payment to the City of Pocatello by another method of my choice for any outstanding amount due.

Your authorization will remain in full force and effect until the City of Pocatello Finance Department has received written notice from you to cancel the authorization. You have the right to stop payment of a debit entry by notifying the City of Pocatello Finance Department in writing at least five (5) business days prior to your account being charged. Requests for adjustments of incorrect charges appearing on your invoice should be made directly to the City of Pocatello Finance Department at 208-234-6214.

Signature (as shown on bank records)

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

City of Pocatello Customer Bank Draft Form

Customer

Customer Address

Bank Draft

Bank Draft Action

Bank Account Type

Voided Check (or Proof of Routing and Account Numbers)

Authorization

Statement of Authorization

Cancellation

Cancellation Request

Signature (as shown on bank records)