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Automatic Draft Request Form
Is this a new request or are you updating your current draft information?
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New Request
Update Current Information
Is this a checking account or savings account?
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Checking
Savings
First Name
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Last Name
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Street Address
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City
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State
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Zip Code
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Phone Number
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Email Address
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Water Account Number
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Please upload a copy of a voided check. If filling this form out from a phone you can take a photo of your voided check. *
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Financial Institution Name
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Bank Routing Number
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Bank Account Number
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By checking the box below, I understand and accept that I am requesting for the City of Belmont to automatically deduct my monthly utility bill payment from the bank account that I have provided and I understand and accept that this payment arrangement will continue every month until I request for this to be stopped and canceled.
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I Accept
By checking the box below, I understand and accept the following terms: My monthly utility bill payment will be automatically deducted from the bank account that I have provided on the 15th of each month. If the 15th falls on a weekend, the payment will be automatically deducted on the following business day. I understand that if the funds are not available on the day that the payment is deducted, I will be charged a $25 returned check fee and will also be responsible for the original payment amount.
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I Accept