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4. AUTHORIZATION FOR AUTOMATIC PAYMENT

   By enrolling in the Automatic Payment program, you authorize your monthly City of Vermillion utility payment to be made from your checking or savings account. The last week of each month you will receive your monthly utility bill. The ACH will be drawn on the first business day after the 10th of the month. Proof of payment will appear on your bank statement. The authority you give to charge your account will remain in effect until you notify us in writing to terminate the authorization.

6. First Name and Middle Initial*
7. Last Name*
8. Phone Number*
9. Email Address*
11. Service Address*
12. Utility Account Number*
14. Bank Name*
15. Bank Routing Number*
16. Bank Account Number*
18. Bank Address*
19. City*
20. State*
21. Zip Code*
23. Type of Account*
    -- Select One --Checking AccountSavings Account
24. Please attach a voided check.*

    If you do not have a check, attach a bank record that includes a complete account number and bank routing number. For further questions, contact the Finance Office at 605-677-7056.

26. Authorization for Automatic Payment*

    I authorize the City of Vermillion and the financial institution named herein to initiate entries to my (our) checking or savings account for utility payments. This authority will remain in effect until I notify the City of Vermillion Finance Office in writing to cancel, notification to be submitted by the 15th of the month to afford reasonable opportunity to act on it. Any automatic payments not honored by the bank will be charged a return item fee.

    1. I authorize.
28. 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.

    1. I agree.
30. Electronic Signature
31. Date*
    Date
33. FOR OFFICE USE ONLY

    Date Received:                                        Received By:                                       Date Entered:                                       

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