Automatic Payment Authorization

**BEFORE YOU BEGIN, PLEASE MAKE SURE YOU HAVE YOUR BANKING INFORMATION READY, INCLUDING THE BANK NAME, ROUTING NUMBER, & YOUR ACCOUNT NUMBER. WE WILL ALSO NEED A PICTURE OF A VOIDED CHECK OR SCAN OF A VOIDED CHECK ATTACHED TO THIS SUBMITTAL, SO THAT WE CAN VERIFY THE INFORMATION ENTERED IS CORRECT.**

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Utility Account Information

The undersigned customer(s) of Dodgeville Utilities hereby authorize Dodgeville Utilities to automatically deduct amounts due under the following agreement for the purpose of paying monthly water, sewer, and garbage service charges.

Customer Account Number *

Customer Name(s) *

Customer Address *

Service Address, if different *

Payment Information

Automatic Payment will be drawn on the 20th of the month (Actual due date of the utility bill) Payment amounts will vary each month. Customer(s) will receive their regular monthly billing notice on the 1st of each month. If you do not receive your bill by the 5th of the month, contact Dodgeville Utilities immediately at (608) 930-7679

Deposit Account Information

Deductions shall be made from the following deposit account

Bank Name *

Routing Number *

Account Number *

Type of Account *

Checking

Savings

Is this a *

Business

Personal

Voided Check *

Files must be less than 2 MB.
Allowed file types: jpg jpeg pdf.

Authorization

The undersigned account holder(s) agree to maintain sufficient funds in the referenced Deposit Account to pay the full amount of each payment on the date it is due. Account holder(s) will be responsible for all fees charged by their financial institute for insufficient funds.

Signature *

Typing your name here constitutes you agree to the terms of this form.

Date *

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Automatic Payment Authorization

Contact Information