HomeMy WebLinkAboutGB_ACH_Fillable_FormBilling Statement Delivery:
Checking:Savings:
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Signature Date
IMPORTANT: Please be sure to include a check marked “VOID” to tell us from which account you want your
payments deducted.
ACH WITHDRAWAL - AUTOMATIC PAYMENT AGREEMENT
City of Oshkosh ● 215 Church Ave, Oshkosh WI 54901
Accounts Receivable: (920) 236-5019
ar@ci.oshkosh.wi.us
your account.
voided check, and I authorize that institution to debit my account for that payment. This authorization will remain in
effect until I terminate it, allowing 10 days prior to payment due date. I have the right to stop payment on individual
entry or to have entries corrected by timely notification to the City of Oshkosh and my financial institution. The City
of Oshkosh also has the right to cancel this agreement at any time by providing timely notification to me.
Failure
to provide a voided check may cause delays of set-up and/or rejections
by the banks.
Account Number:
BANK ACCOUNT INFORMATION
Bank Name:
Bank Address:
Bank Telephone #:
E-mail:
Street or P.O. Box address:
City:
deducted 1st of the month following
Saturday, or Sunday, the payment will be deducted on the next business day. Example: Invoice date 02/11,
payment will be deducted 03/01.
State:
Routing Number:
If the payment is rejected by the bank, the City will impose a $35 return item fee on your open invoice.
Please print name, address and account number exactly as they appear on your bill:
Name:
Service Address:
CID#: __ __ __ __ __ __ __ __ __ __
Telephone #:Best time to call: