Direct Payment via ACH is a free service authorizing your monthly City of Yankton water, sewer, & garbage utility bill payment. The ACH will be drawn directly from your checking or savings account on the first business day prior to the 10th of the month. Proof of payment will appear on your bank statement and monthly utility bill.

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Utility Billing Information

Printed Name on the Account:

 *

Printed Name on the Account:

Utility Account Number:

 *

Utility Account Number:

Utility Address:

 *

Utility Address:

Phone Number:

 *

Phone Number:ext.

Email Address:

Email Address:

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Customer Authorization for Direct Payment via ACH

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.

Check one: 

 *

Check one:

Begin Payment

Change Information

I (we) authorize The City of Yankton ("COMPANY") to electronically debit my (our) account and, if necessary, to electronically credit my (our) account to correct erroneous debits as follows:

Account Type:

 *

Account Type:

Checking

Savings

at the depository Financial Institution named below ("DEPOSITORY").  I (we) agree that ACH transactions I (we) authorize comply with all applicable laws.

Depository Name:

 *

Depository Name:

City:

 *

City:

State:

 *

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Bank Routing Number:

 *

Bank Routing Number:

Bank Account Number:

 *

Bank Account Number:

Name(s) on the account:

 *

Name(s) on the account:

Debit transaction frequency:

☐ Single Entry (one-time payment)

☐ Multiple Entries (multiple entries that may not occur at substantially regular intervals)

How will subsequent Entries be allowed?

☐ Telephone

☐ Internet

☐ Other

 ☒ Recurring Entries (entries that recur at substantially regular intervals, without further affirmative action by the Receiver)

Date of debit (if Single Entry) or date of first debit:

 *

Date of debit (if Single Entry) or date of first debit:

Number of and/or frequency of debits: ____Once a month on the 8th or 9th ____________

 Authorized debit amount (or method for determining amount): Yankton Utility Bill Amount Due

I (we) understand that this authorization will remain in full force and effect until I (we) notify the City of Yankton Finance Office via writing that I (we) wish to revoke this authorization. I (we) understand that the City requires at least 2 weeks prior notice in order to cancel this authorization.

 *

I (we) understand that this authorization will remain in full force and effect until I (we) notify the City of Yankton Finance Office via writing that I (we) wish to revoke this authorization. I (we) understand that the City requires at least 2 weeks prior notice in order to cancel this authorization.

I Agree

Printed Signature

Date

Attach Voided Check Here:

 *

Attach Voided Check Here: Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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