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Utility - ACH Bank Draft Application

  1. (please include City, State, and Zip code)

  2. Is your mailing address different from your service address?

  3. (please include City, State, and Zip code)

  4. (please include City, State, and Zip code)

  5. This is the first set of numbers on the check

  6. This is second set of numbers on the check

  7. Electronic Signature Agreement*

    I hereby authorize the City of Monroe to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) checking account indicated above. This authority is to remain in full force and effect until written notice from me has been received by the company in such a manner as to afford reasonable time to act on it. 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.

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