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1290 S. Public Road • Lafayette, Colorado 80026 • [PHONE REDACTED] • lafayetteco.gov Automatic Withdrawal for Your Utility Bill – Summary Thank you for signing up for automatic withdrawal of your utility bill. To enroll, return the completed form with: • A voided check (for checking accounts), OR • A letter from your bank with routing and account details (for savings accounts). Forms without these will be returned. Important Rules: • You’ll continue receiving your utility bill. Auto-pay begins with your second billing cycle after enrollment. "Paid by Draft" will appear on your bill when active. • Payments are withdrawn on the due date listed on your bill. • To dispute a charge, contact the finance department at least five business days before the due date. • If two payments are declined within 12 months, you’ll be removed from the program and charged a $30 fee per returned payment. • To cancel auto-pay, submit a written request at least five business days before the due date. • Changing bank accounts? Submit a voided check from the new account along with your address and utility account number. • If your property becomes a rental, ACH payments will stop when a new tenant moves in, and you must reapply. • If removed from the program, you must wait 12 months before reapplying. • Final bills are NOT paid through ACH—you must use another payment method. For questions, contact the City of Lafayette Finance Department at [PHONE REDACTED] or email [EMAIL REDACTED]. Keep this copy for your records. ---PAGE BREAK--- 1290 S. Public Road • Lafayette, Colorado 80026 • [PHONE REDACTED] • lafayetteco.gov City of Lafayette – Utility Auto-Pay Authorization Form Utility Account Number: Account Holders Name: Service Address: Bank Information: (Attach a voided check or bank letter) Bank Name: Bank Routing Number: Bank Account Number: Authorization Agreement I (we) authorize the City of Lafayette to automatically withdraw utility payments from my (our) checking or savings account at the financial institution listed above. These ACH transactions will comply with U.S. banking regulations. • Payments will be withdrawn on the due date stated on my (our) utility bill each month. • To stop payment, I (we) must notify the City of Lafayette Finance Department in writing or by email at least five days before the scheduled withdrawal. • If a payment is rejected twice within 12 months, the City will cancel my (our) enrollment in the auto-pay program. By signing below, I (we) acknowledge and agree to the terms outlined above and in the attached letter. Signature: Date: Return Completed Form To: City of Lafayette Finance Department 1290 S Public Rd Lafayette, CO 80026 [EMAIL REDACTED]