Form Center

2. 
4. 
6. Name (as shown on Bank Account)*
8. Service Address*
10. City*
11. State*
12. Zip Code*
14. Email Address
15. Phone Number*
16. Account number as shown on Utility Bill
18. Please upload a copy of a voided Check *
    Please be sure the bank account and routing number are visible. If you are uncomfortable uploading a check, please print this form when complete and bring to the Utility Billing Office.
19. Description of Debit
    Your debit will show as "Crestview Utility Bill"
21. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. By your Electronic Signature you are agreeing to the Authorization Agreement for Electronic Funds Transfer "I hereby authorize the City of Crestview, as my agent, to automatically debit my bank account for payment of all utility bills issued by the City. The City will advise, by notice with my bill, of the date my account will be debited. I understand I must notify the City promptly upon receipt of my utility statement of any dispute regarding the amount of the bill. I understand the City may impose a late fee (10% of past due amount)if the draft is not paid by my bank by the due date for reasons such as insufficient funds or my account being closed (an additional $25.00 Service charge may be applied in either case), and that I remain personally liable for the total amount of my bill in such event. This authorization will be in effect until either party gives written notice to the other of termination. I understand my notice must be received by the City in time for it to have a reasonable opportunity to act."

    1. I agree.
23. Electronic Signature*
24. Date *
    Date
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field