Pre-Authorized Utility Bill Debit/ACH Form

Each month the full amount due will be withdrawn automatically by your financial institution and submitted to the City of Horace for payment of your utility bill. Partial payments are not accepted. If sufficient funds are not available, an NSF charge by both your bank and the City of Horace may be applied to your account. Funds are withdrawn on the 25th of each month.

Customers signed up for ACH payments will receive Utility bills by email to the email address provided, unless a paper copy is requested.

All information below must be completed
I understand that it is my responsibility to notify the City of Horace if I change banks by submitting a new form before the 23rd of the month of the change. My electronic signature below authorizes the City of Horace and my financial institution (listed below) to electronically debit my bank account on the 25th of each month to pay my utility bill. I understand that if funds are not available, I may be charged an NSF fee of $25.00 per transaction. This authorization will remain in effect until I have sent written authorization to terminate.

Customer Information

Financial Institution

Checking Account Information

Signature