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Auto-Pay Submission Form

  1. City of Anacortes - Auto Pay Application Form

  2. Customer Information

  3. Fill-in only if different from service address

  4. Fill-in only if different from service address

  5. Please Enter Checking Account Information Here:

    "Auto-Pay" will show on your next billing in the "amount enclosed" area

  6. Enter the 9 digits that appear at the bottom left of your check (109800033 in the example)

  7. Enter your account number (333562222 in the example). Do not include the check number (3333 in the example).

  8. Check Example
    Void Check Sample

  9. Agreement and Signature

    By submitting this application, I authorize the City of Anacortes to withdraw from my account the total amount due on my billing statement on the due date indicated. I understand that if the account does not have sufficient fund to cover the withdrawal there will be a returned bank item fee charged to my utility account. Withdrawals will continue until I request that the City of Anacortes cancel Auto-Pay. Any payment in process at the time I cancel may still be deducted from this account.

  10. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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