City Of Bardstown Automatic Payment Program Authorization Form

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City of Bardstown
Automatic Payment Program
Save Time and Money
Our Automatic Payment Program is a thrifty and convenient way to pay your monthly bill. You will no
longer have to stand in line at City Hall to make a payment. If you normally pay by mail, you can save
on postage! No check writing and no late payments. It’s accurate, efficient and reliable.
How it Works
You will receive your bills in the mail. (Cable TV is optional) We will contact the bank and the
automatic payment will be made for you on the due date.
If you would like more information on our Automatic Payment Program please contact one of
our customer service representatives at 348-5947 or fax to 348-2433.
P
C
B
, 220 N
F
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, B
, K
40004
LEASE DETACH AND RETURN TO
ITY OF
ARDSTOWN
ORTH
IFTH
TREET
ARDSTOWN
ENTUCKY
I hereby authorize the City of Bardstown to instruct my financial institution to make my Utility, Cable TV, and/or
Cable Internet payment from the bank account listed below. I understand that I control my payments and if at
any time I decide to discontinue the payment service, change or close my bank account, I will notify the City of
Bardstown thirty days prior to the withdrawal date. This form will not be valid if all information requested is
not provided.
Please check one:
New Automatic Payment Plan Customer
Change of Bank Information
Please check the boxes below for the accounts you wish to sign up for the Automatic Payment Program:
Utility
Cable TV
Cable Internet
Customer Name (as shown on bill) _______________________________________Phone #___________________
Address_____________________________________City____________________State & Zip__________________
Financial Institution_____________________________________________________________________________
Type of Account:
CHECKING
SAVINGS
Bank Account Number__________________________________
(Please include a voided check. Deposit slips are no longer valid for this service)
Utility Account Number__________________________ Cable TV/Internet Number__________________________
Signature_______________________________________________Date___________________________________
Date you want the automatic payments to start_______________________________________________________
For office use only: CSR initials _______________ Date______________

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