City of Buchanan- Direct Payment Authorization Form

Utility Billing Account # I__I__I__I__I-I__I__I__I__I__I__I-I__I__I__I__I-I__I__I

Follow these 5 easy steps to start paying your bills automatically!

#1        Please print your customer information:

Name______________________________________________________

            Service Address______________________________________________

            Mailing Address (if different)____________________________________

            Daytime Phone (____) _______________  E-mail___________________

#2        Provide your signature for authorization:

I authorize the City of Buchanan, or its agents, and the financial institution listed below to

deduct my payments from the checking or savings account provided for each billing period. 

This authority will remain in effect until I have cancelled it in writing,

This form cannot be processed without your signature

Signature____________________________    Date_______________

#3        Provide the required financial information below:

Name of Financial Institution ____________________________________

            Branch Name and Address_____________________________________

Checking    (Attach Voided Check)  ~or~                 Savings         

Bank Transit Routing Number                       

I:

I:

Bank Account Number

#4        Photocopy this form for your records

#5        Mail original to:         City of Buchanan ~or~ Fax to: 269-695-4330

Automatic Payment Plan

                                                302 N. Redbud Trail

Buchanan, MI 49107