City of Klamath Falls

Utility Billing Department

222 S. 6th Street, Klamath Falls, OR 97601

(541) 883-5301 Billing / (541) 882-1418 Fax

TTY (541) 883-5324 (Hearing Impaired)

IMPORTANT – PLEASE READ BEFORE SIGNING!!!!!!!!!

Bank Draft Authorization

I authorize my financial institution to honor pre-authorized drafts by the City of Klamath Falls from my bank account for utility payments. It is understood that my bank draft will be continuous until 30 days after my written notification of cancellation has been received by the City of Klamath Falls. When my financial institution honors the draft by charging my account, such drafts constitute my receipt for payment.

A voided check is required with all bank draft applications. Changes or cancellations can not be made by telephone. If at any time I wish to cancel the automatic draft service, it is to be submitted in writing to the City of Klamath Falls 30 days prior to the day I want the drafts to be discontinued. Failure to do so will make the subsequent draft non-refundable. If I change my financial institution or change my account with the same financial institution, or if I move to a different location, I understand that I will need to complete a new contract and provide another voided check to the City of Klamath Falls.

The City of Klamath Falls will continue to mail out my monthly bills so that I will know

the amount that is being withdrawn from my bank account. If an entry is erroneously initiated by the City of Klamath Falls to my bank account, I shall have the right to have the amount of such entry refunded within fifteen (15) calendar days following notification to the City and verification of such error.

Should any draft from the City of Klamath Falls not be honored by my financial institution when received by them, I understand that the City will treat the dishonored draft as a returned check. The amount of the draft will be charged back to my utility account along with the current service fee for the returned draft. I understand that upon notification by the City of the returned draft, the payment of my utility account is to be made by me in person. Lack of prompt payment could affect continuation of my utility service. After two dishonored drafts, I will automatically be removed from this service.

Customer Name: ______(please print)

Customer Account #: ______

Service Address: ______

Telephone #: ______

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CUSTOMER SIGNATURE DATE

Please attach a voided check and submit with your authorization.

The bank draft requires a “pre-note” (test) before the first draft can be withdrawn from your bank account. The first month a test will be sent in the amount of $00.00 to verify that all the banking information is correct. You will, therefore, need to pay your first month’s utility bill after you submit this authorization form with a check through the mail, a debit/credit VISA or MasterCard by telephone, or you may pay in person at the address listed above. The following month your bank account will be drafted for the amount of your bill on the due date and monthly thereafter for as long as you wish this service to continue. If the date falls on a weekend, the draft will be withdrawn on the following Monday.

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Customer’s Initials

Utility Billing Bank Draft Authorization Form, Page - 1