Borough Of Zelienople, PA
APPLICATION  FOR AUTOMATIC PAYMENT OF UTILITY BILLS

In order for the automatic payment option to be initiated, the signed original copy of the application must be submitted to the Borough Office.

AUTHORIZATION FOR DIRECT PAYMENT

I authorize the Borough of Zelienople and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution 3 days before my account is charged.

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(Name of Financial Institution)                                                     (Branch)

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(Address of Financial Institution)         (Street)                 (City)           (State)             (Zip)

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(Signature)                                                                                               (Date)

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(Name Please print)

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(Address Please print)

 

Checking Acct No. _______________________ or Savings Acct. No. ____________________

Financial Institution Routing Number: ______________________________________________

Zelienople Borough Billing Account Number(s): _____________________________________

_____________________________________________________________________________________

RETAIN FOR YOUR RECORDS

On ________________, I authorized Zelienople Borough to initiate electronic entries to my checking/savings account and have agreed to the terms listed on the authorization. I may revoke my authorization with the company at any time by writing to the address above.

Account will be debited the 10th day of the month unless such day falls on a weekend or holiday. In that event, accounts will be debited on the next business day.

 

 

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