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Checking/Savings Automatic Payment

  1. City of Bismarck Water Utility Department
    601 S 26th Street, Bismarck ND 58504
    Mail To: PO Box 5555, Bismarck ND 58506-5555
    Phone (701) 355-1700, option 1        Fax (701) 221-6840
  2. Consent for Automatic Payment:    By signing this consent agreement, the undersigned customer of the City of Bismarck agrees to have his/her monthly municipal services bill deducted from his/her designated checking or savings account. Please complete this form, sign it, attach a voided check and return to the City of Bismarck Water Utility Department.
  3. Deduct from:*
  4. Please Attach
    Voided Check
  5. The City of Bismarck may cancel this automatic billing agreement at any time. I consent to the City of Bismarck billing my checking or savings account directly. If I wish to cancel automatic billing of my checking or savings account, I will notify the City of Bismarck Water Department in writing at least two weeks prior to the next billing date. I understand that there will be a service charge for any payments returned as NSF, and I will be disqualified from the automatic billing plan.
  6. Signature of Account Holder(s):
  7. Date
  8. Leave This Blank: