City of Underwood

PO Box 168

Underwood, ND 58576

442-5481

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS) Name: Click here to insert your name. I (we) hereby authorize the City of Underwood, to initiate debit entries to my (our) (select one) ☐ Checking Account or ☐ Savings Account indicated below at the depository financial institution named below, and to debit the same to such account approximately the 10th of every month. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law. Financial Institution / Bank Name: Click here to insert name. City: Click here to insert city. State: Click here to insert state. Zip: Click here to insert zip. Routing Number (9 digits): Click here to insert #. Checking Account #: Click here to insert #. or Savings Account #: Click here to insert #. This authorization is to remain in full force and effect until the City of Underwood has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the City of Underwood and DEPOSITORY a reasonable opportunity to act on it. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that City of Underwood may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form. Name(s): Click or tap here to enter text. Utility Account #(s): Click or tap here to enter text.	Signature: ______________________________________	______________________________________	Date: __________________________

Do not include check number

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Office Use Only: ACH SETUP COMPLETED:____________________DATE:_______________________