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Automatic Debit Authorization Form

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  2. CITY OF FATE LOGO
  4. Automatic Debit Authorization Form
  15. Checking / Savings Information
    Include a voided check. This can be emailed, faxed, brought in office or in the drop box.
  23. I will continue to make payments as usual until my bill states "PAID BY DRAFT." Failure to do so could result in late fees and/or interruption of service.
  25. I authorize the City of Fate, TX to debit the account indicated above to pay my monthly utility bill. I understand that my bank/credit card account will be debited for the total amount due, on the due date. (Should the due date fall on a weekend or holiday, the draft will occur on the business date after the due date). If the City of Fate, TX erroneously debited funds from the above account, I authorize the City of Fate, TX to initiate the necessary credit entries not to exceed the total amount of the entry in question.
  27. This authorization will remain in effect until written authorization has been received by the City of Fate, TX to terminate automatic debit. The customer is responsible for notifying the City of Fate, TX in writing of any changes to their bank account or credit card at least FIVE (5) business days prior to being charged on the due date. A $35 service fee will be charged for any debits returned unpaid due to insufficient funds, closed account, expired card, etc...
  33. Cancel Automatic Debit
    I authorize to cancel my automatic draft. Please note we must receive cancellation request a minimum of FIVE (5) business days prior to being charged on the due date.
  37. Internal Use Only
  39. Entered by: _____________________
  40. Date: __________________
  44. Phone: 972-771-4601 Opt: 2
  46. Fax: 972-722-8266
    47. Leave This Blank:

  49. This field is not part of the form submission.