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ELK RIVER MUNICIPAL UTILITIES <br />AUTHORIZATION FOR AUTOMATIC BILL PAYMENT <br />(Required for Budget Plan) <br />Participation in the Budget Payment Plan requires that your utility payments be made by <br />Automatic Bill Payment. You authorize regularly scheduled payments to be made from your <br />checking or savings account. For your convenience, you will continue to receive your utility bill <br />at the end of each month, showing the amount due on the 15`n of the next month. The amount <br />shown due on your utility bill will be drawn from your checking or savings account on the 15`n <br />of the next month (or the next business day if the 15`n lands on a weekend or a holiday.) Each <br />payment will be itemized on your monthly bank statement. There is no charge for this <br />transaction. <br />Please complete the authorization form below and include a voided check or withdrawal slip. <br />Customer Name <br />Phone Number(s) <br />Service Address <br />City <br />State Zip <br />Account Number of your Elk River Municipal Utilities Bill <br />Financial Institution (Bank) Name <br />Type of Account Checking (please enclose a voided check) <br />Savings (please enclose a withdrawal slip) <br />Account Number <br />Financial Institution's Routing /Transit Number <br />Signature Date <br />