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Authorization Agreement for Direct Payments (ACH Debits)

2. I (we) hereby authorize City of Weatherford to initiate debit entries to my(our) account indicated below at the Depository named below, and further authorize the Depository to debit the same.

   I (we) hereby authorize City of Weatherford to initiate debit entries to my(our) account indicated below at the Depository named below, and further authorize the Depository to debit the same.

3. Please select account type*

   1. Checking Account
   2. Savings Account

5. Bank Name *

7. First Name*

   Name on Bank Account

8. Last Name*

10. Bank Routing Number *

11. Bank Account Number*

13. Important
    First draft will have to pre-note the bank, please allow one full billing cycle for draft to go into effect.

    First draft will have to pre-note the bank, please allow one full billing cycle for draft to go into effect.

15. This authorization is to remain in full force and effect until the City has received written notification from me (us) of its termination in such time and in such manner as to afford the City and Depository a reasonable opportunity to act on it.

    This authorization is to remain in full force and effect until the City has received written notification from me (us) of its termination in such time and in such manner as to afford the City and Depository a reasonable opportunity to act on it.

17. Authorization Provided By:*

19. City of Weatherford Account Number *

21. Email Address *

Leave This Blank:


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

    This field is not part of the form submission.

25. Submit

* indicates a required field