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Checking/Savings Automatic Payment Printable Form

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
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.
Name on City of Bismarck Utility Billing Account*
City of Bismarck Utility Billing Account Number*
Address where service provided*
Daytime Phone Number*
Name of Bank or Financial Institution*
Bank Routing Number
Bank Account Number
Deduct from:*
1. Checking Account
2. Savings Account
Please Attach Voided Check
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.
Signature of Account Holder(s):
_______________________________________
_______________________________________
_______________________________________
Date
_____________________________
_____________________________
_____________________________

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Checking/Savings Automatic Payment Printable Form