ACH Recurring Payment Authorization

Enroll in automatic monthly payments for your utility/garbage bill.

ACH Recurring Payment Authorization Form

With our Direct Payment Program, you will not have to send another check to pay for your monthly utility/garbage bill. When you enroll, we will automatically deduct the "Total Amount Due" (found on your bill) or your budget billing amount from your checking/savings account on the 30th of each month.

Please complete the information below and attach a copy of a voided check to this form.

I (we) hereby authorize the City of Lenox to initiate debit entries to my (our) account indicated below at the depository financial institution named below and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law.

Depository Financial Institution

Depository Name

City

State

Zip

Account Information

Routing Number

Account Number

Type of Account

Checking Savings

Utility Account

Utility Account Holder's Name

Utility Account Number(s)

Date

Signature

Signature If printing to sign by hand, you may leave this field blank.

Attach a copy of a voided check to this form.

This form is not submitted online. Please print and mail, or bring the completed and signed form with a voided check to City Hall at 200 S Main St, Lenox, IA 50851.