Form Center

Direct Payment Authorization Form

2. 

5. Direct Payment Authorization Form

7. The City of Zanesville is now offering Direct Payment to our utility customers. This is a FREE service that allows you to have your utility payment deducted automatically from your checking or savings account each month. Please provide a "voided" check and fill out and sign the bottom portion and return to the billing office. As a participant of Direct payment, I agree to and understand the following:
   * It will take one month to establish this process. Until that time, I am responsible to pay the bill directly to the City of Zanesville.

   * It will take one month to establish this process. Until that time, I am responsible to pay the bill directly to the City of Zanesville.

9. * When this process is setup, a message will appear on utility bill "PAID BY DRAFT"

   * When this process is setup, a message will appear on utility bill "PAID BY DRAFT"

11. * Authorize the City of Zanesville to debit my checking or savings account for all monthly utility bill charges.

    * Authorize the City of Zanesville to debit my checking or savings account for all monthly utility bill charges.

13. * Ensure that sufficient funds are in my checking or savings account to cover utility bill charges.

    * Ensure that sufficient funds are in my checking or savings account to cover utility bill charges.

15. * Your checking account will be debited on the DUE DATE stated on the bill each month

    * Your checking account will be debited on the DUE DATE stated on the bill each month

17. * One refused automatic fund transfers may cancel this agreement at the option of the City of Zanesville

    * One refused automatic fund transfers may cancel this agreement at the option of the City of Zanesville

19. * Promptly notify the City of Zanesville of any change to my checking or saving account. If a change occurs it is my responsibility to provide the City of Zanesville with the current account information.

    * Promptly notify the City of Zanesville of any change to my checking or saving account. If a change occurs it is my responsibility to provide the City of Zanesville with the current account information.

22. COMPLETE AMD EMAIL WITH A VOIDED CHECK

24. First Name*

25. Last Name*

27. Service Address*

29. Phone Number*

30. Utility Account Number*

32. Financial Institution Name*

34. Financial Institution Address*

36. City*

37. State*

38. Zip Code*

40. Bank Routing Number*

41. Bank Account Number*

43. Type of Account

    1. Checking

    1. Savings

45. I hereby authorize the City of Zanesville to initiate debits to the financial institution indicated for the purpose of paying my monthly utility bill with the City of Zanesville. The financial institution is authorized to debit my account. This authority is to remain in effect until either I revoke authorization by giving 30 day prior written notice to the City of Zanesville; it is canceled by the City of Zanesville under the conditions stated; or upon termination of my services with the City of Zanesville. I have read and agree to the terms and conditions outlined.

    I hereby authorize the City of Zanesville to initiate debits to the financial institution indicated for the purpose of paying my monthly utility bill with the City of Zanesville. The financial institution is authorized to debit my account. This authority is to remain in effect until either I revoke authorization by giving 30 day prior written notice to the City of Zanesville; it is canceled by the City of Zanesville under the conditions stated; or upon termination of my services with the City of Zanesville. I have read and agree to the terms and conditions outlined.

47. Signature*

48. Date*
    Date

Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field