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Checking/Savings Automatic Payment Printable Form

  1. City of Bismarck Logo
  2. City of Bismarck Utility Billing

    601 S 26th Street, Bismarck ND 58504

    Mail To: PO Box 5555, Bismarck ND 58506-5555

    Phone (701) 355-1700, option 1

  3. 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.
  4. Deduct from:*
  5.                                                                                        Please Attach Voided Check

  6. 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.
  7. Signature of Account Holder(s):
  8. Date
  9. Leave This Blank: