AUTHORIZATION AGREEMENT FOR ACH DEBITS (for Sewer Payments Only) City of Sanibel Federal ID Number: 59-1568877
I (we) hereby authorize the City of Sanibel herein called the company, to initiate debit entries and/or correction entries to our checking account indicated below at the depository named below, herein called depository, to credit the same such account. CLICK HERE TO DOWNLOAD THE PDF FORM
DEPOSITORY (BANK):
BRANCH:
CITY:
STATE/ZIP:
BANK TRANSIT /ABA NUMBER:
BANK ACCOUNT NUMBER:
This authorization is to remain in force until company has received written notification from me (or either of us) in such time and in such manner as to afford company and depository reasonable time to terminate this ACH debit. NAME(S) ON THE ACCOUNT: DAYTIME TELEPHONE NUMBER: ( ) ( ) SIGNATURE: DATE:
SIGNATURE:
DATE:
E-MAIL ADDRESS: PROPERTY ADDRESS:
ACCOUNT #:
CUSTOMER #:
Please return to: City of Sanibel Attn: Finance Department 800 Dunlop Road Sanibel, FL 33957 Fax:239-472-3065 E-mail – billings@mysanibel.com
PLEASE ATTACH A VOIDED CHECK FROM THE ABOVE-REFERENCED ACCOUNT
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