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CUSTOMER NAME ACCOUNT # PHONE NUMBER I hereby authorize the City of Jerome to initiate electronic entries from my checking account as indicated below. I also request the financial institution named below to process the entries. I understand that my Utility payment will be deducted automatically from my bank account. I also understand that if there are insufficient funds to cover my Utility payment, I will replace the automatic payment with cash or money order. FINANCIAL INSTITUTION: City Branch Transit Routing Number: Account Number: Check one: Checking Savings SIGNATURE DATE CITY OF JEROME UTILITY DEPARTMENT DIRECT PAY AUTHORIZATION FORM