Utility Billing Department

Bank Draft Form

Email Customer Service with any questions: customerservice@cityofconway.com

By checking this box, you authorized the City of Conway to charge your bank account indicated below on the 15th of each month for payment of your City of Conway Utility Bill.*

I Agree

Account Number*

Check this box if you also have an Irrigation Account

I have an Irrigation Account

Name on Account*

Telephone Number

Service Address*

Email Address

GO PAPERLESS!

Yes!

If you do not provide a voided check to verify the account/routing numbers, you are responsible for the information provided. Please make sure your information is legible and on the appropriate line.

Bank Account Name*

Bank Account Number*

Routing Number*

Voided Check

By checking this box, I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the City of Conway in writing of any changes in my account information or termination of this authorization. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. Items returned unpaid (NSF, Closed Accounts, etc.) will be charged a $30 service charge. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

I Agree*

I Agree

Signature*

Date*