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4. AUTHORIZATION FOR PAPERLESS BILLING

   By electing Paperless Billing you will receive your bill the instant that it is ready – no more waiting for the mail. This service is easy to start and you can cancel at any time. Sign up today by completing the form below. If you have any questions, please contact the Finance Office at (605) 677-7056 or [email protected].

6. First Name and Middle Initial*
7. Last Name*
8. Phone Number*
9. Email Address*
11. Service Address*
12. Utility Account Number*
13. Do you still wish to receive a postcard in the mail?*
    -- Select One --YesNo
15. Authorization for Paperless Billing*

    I authorize the City of Vermillion to e-mail my utility bill. This authority will remain in effect until I notify you in writing. I understand it is my responsibility to notify the City of Vermillion if my e-mail address changes.

    1. I authorize.
17. 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.
19. Electronic Signature
20. Date*
    Date
22. FOR OFFICE USE ONLY

    Date Received:                                        Received By:                                       Date Entered:                                       

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24. Submit Submit and Print

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