Automatic Withdrawal for Utility Payments

* Sign up to have your quarterly utility payment withdrawn from your checking or savings account on the due date.

* You will continue to receive your quarterly invoice, marked DO NOT PAY - AUTOMATIC PAYMENT WITHDRAWAL.

* Please allow 30 days for set up. If your utility payment is due in the next 30 days, you will need to make that payment. The following quarter your payment will be automatically withdrawn.

Business Name, If Applicable (As It Appears on the Utility Account)

Service Address

Utility Account Number (Can be found on a Utility invoice)

Phone Number

Request

Checking Account

Savings Account

Change Existing Enrollment

Cancel ACH Withdrawal

Financial Institution

Routing Number

Bank Account Number

Signature

First Name

Last Name

Choose how to sign

Draw Type

I hereby authorize the City of Neenah to initiate debit entries to the above checking/savings account and financial institution, or terminate automatic withdrawal, as requested above. I am legally authorized to make this request.