2. ACH/Bank Draft Payment Authorization Agreement

   I (we) hereby authorize and request the "City of Idaho Falls", hereinafter called CITY to effect payment for any amounts owing me (either for us) to the CITY as such amounts become due by initiating debit entries to my (our) account indicated below in the bank names below, hereinafter called BANK and I (we) authorize and request Bank to accept any debit entries by the CITY to such account and to debit the same account without responsibility for the correctness thereof.

   PDF Version of Authorization Agreement

4. BANK NAME:*
6. BANK ADDRESS:
8. CUSTOMERS BANK ACCOUNT NUMBER:*
9. BANK ROUTING NUMBER:*
11. CUSTOMER UTILITY ACCOUNT NUMBER
13. PAYMENT OPTION:*

    1. Actual monthly utility charges
    2. Budget Billing Monthly Plan
14. ACCOUNT TYPE:*

    1. Checking
    2. Savings
16. It is understood that this agreement may be terminated by me (either of us) at any time by written notification to the CITY or BANK. Any such notification to the CITY shall be effective only with respect to entries initiated by the CITY after receipt of such notification and a reasonable opportunity to act on it. Any such notification to the CITY shall be effective only with respect to entries debited to my (our) account by BANK after receipt of such notification and reasonable time to act on it. It is understood that all debit entries initiated by the CITY pursuant to this agreement shall be subject to the following provisions:
18. (1) If the amount of the entry to be initiated by the CITY differs from that of the next previous entry initiated pursuant to this agreement, the City shall, within no less than seven (7) calendar days before such succeeding entry is to be debited to CUSTOMER'S account, send the CUSTOMER written notification of the amount of such entry. Similarly, if any change is made by the CITY in the date of the billing cycle on or after which such entries are to be debited to such account, the CITY shall, within not less than seven (7) calendar days before the first entry to be affected by such change is to be debited to such account, send the CUSTOMER written notification of the new date on or after which such entries are to be debited to such account. The provision will not apply if the CUSTOMER has authorized the initiation of a single entry to his account or if the CUSTOMER has agreed that entries representing indebtedness to his account may be debited at any time after the indebtedness is incurred.
20. (2) CUSTOMER may, by notice to BANK, stop payment of any initiated or to be initiated by the CITY to CUSTOMER'S account pursuant to this agreement but such notice must be received by BANK in such time and in such manner as to afford BANK a reasonable time to act on it. An oral notice shall be binding on BANK only for fourteen (14) calendar days unless confirmed in writing within that period.
22. (3) if an entry is erroneously initiated by the CITY to CUSTOMER'S account, CUSTOMER shall have the right to have the amount of such entry credited to such account by BANK if within (15) calendar days following the date on which BANK sent or made available to CUSTOMER a statement of account or notification pertaining to such entry, stating that such entry was in error and requesting BANK to credit the amount thereof such account.
24. CUSTOMER NAME(S) please print:*
26. CUSTOMER ADDRESS:*
28. Phone Number
29. Email*
31. Customer Agreement*

    By selecting the "I Agree" button, you are signing this Agreement electronically. You agree that your electronic signature is the legal equivalent of your handwritten signature and you consent to be legally bound by this Agreement's terms and conditions.

    1. I Agree
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33. 1. Receive an email copy of this form.
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