ACH Autopay Enrollment or Change

ACH Auto Pay Enrollment or Change Form

Please complete this form to enroll in ACH Auto Pay or update the banking information for an existing utility account.

If you complete this form after the 20th of the month, the change will NOT take effect for the current month.

Before you begin:
- This form typically takes approximately 5 mintes to complete
- Please have your banking information available before starting

Customer Information
Customer Name

First NameLast Name
Utility Service Address
Phone Number

Area CodePhone Number
Email
example@example.com
Date

MonthDayYear

Banking Information
Financial Institution
Type of Account
Routing Number
This is specific to your bank and is always 9 digits
Account Number
ACH Autopay Authorization Agreement

I hereby authorize Spanish Fork City to initiate automatic withdrawals from my account at the financial institution listed for the full balance due on my utility account each month. The withdrawal will occur on the utility bill due date, or on the next business day if the due date falls on a weekend or holiday.

I understand that I am responsible for paying a $20 returned payment fee for any payment that is returned to Spanish Fork City for any reason. If more than two payments are returned, I understand that I will be removed from ACH Autopay and will be required to pay a utility deposit.

I agree not to hold Spanish Fork City responsible for any delay or loss of funds due to incorrect or incomplete information provided by me or my financial institution, or due to an error by my financial institution in processing the withdrawal.

I understand that this authorization will remain in effect until Spanish Fork City receives an updated ACH Autopay authorization form, or until a deposit is paid.

I further understand that if I make a payment using another method, it must be received by the 20th of the month. Otherwise, the scheduled ACH Autopay may still be processed on the due date, and I accept responsibility for any bank or credit union fees that may result.

This authorization is governed by the rules of the National Automated Clearing House Association (NACHA) and applicable state and federal laws governing electronic fund transfers.
Signature - ACH Autopay Authorization

Please review Spanish Fork City's Privacy Policy Statement before submitting this form.

Spanish Fork City's Privacy Policy Statement
Date and Initial:

_______________ Save New Application

_______________ Setup in Caselle

Notes:
Should be Empty:

Customer Information

Banking Information