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Recurring Payment Authorization Form (ACH) Please sign and complete this form to authorize the City of Laramie to make a ACH debit from your financial institution account. Once you have completed this form please attach a voided check of the account you wish us to debit from for verification and security purposes. By signing this form, you give the City of Laramie permission to debit your account the total amount due as indicated on your City of Laramie Account Statement. This is permission for transactions to be debited on the due date each month, and does not provide authorization for any additional unrelated debits or credits to your account. For your initial setup a completed authorization form along with a voided check must be submitted to the City of Laramie Municipal Services Department located at City Hall. Please complete, in full detail the information below: Per Ordinance the financial institution account holder must be the owner of the property and the same as the name on the utility account. CITY OF LARAMIE Administrative Services Department PO BOX C Laramie, Wyoming 82073 PHONE: (307) 721-5222 PHONE: (307) 721-5324 Email: [EMAIL REDACTED] Name of Financial Institution: Address of Financial Institution: Financial Institution Routing Number: Financial Institution Account Number: Checking Account Savings Account Customer Name: Water Account Number: Address of Service: Signature: Internal Use Only Form Written by: Date: H.T.E. Changes made by: Date: