Automatic Draft Request Form

Is this a new request or are you updating your current draft information? **If your previous/current account draft has recently been stopped, you may not be able to restart draft at this time. Please reach out to apaul@cityofbelmont.org for any insight or concerns before remitting a request, thank you! *

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

All changes to the account information or bill cost must be received by the 10th of the month to be effective for the due date in the same month. Please reach out to customerservice@cityofbelmont.org with any questions or concerns prior to the 10th of the month. Funds cannot be returned to your bank account and will only be credited to the utility account balance if changes are made. *

I Accept

If submitting this after the 10th of the month and have a balance due, a manual payment will be required to not incur additional fees and/or interruption. The draft will then begin on the following month's due date. *

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