Automatic Draft Request Form

Is this a new request or are you updating your current draft information? *

Is this a checking account or savings account? *

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Water Account Number *

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. * *

Financial Institution Name *

Bank Routing Number *

Bank Account Number *

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. *

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. *

I Accept