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2. City of Anacortes - Auto Pay Application Form
4. *DO NOT FILL THIS OUT IF YOU HAVE ALREADY SIGNED UP THROUGH ANOTHER FORM OF PAYMENT USING YOUR BANK OR PAYMENTUS, PLEASE*
6. Utility Account Number*
8. Service Address*
10. Customer Information
12. First Name*
13. Last Name*
15. Mailing Address
    Fill-in only if different from service address
17. City
    Fill-in only if different from service address
18. State
19. Zip Code
21. Daytime Phone Number*
22. Alternate Phone Number
24. Email Address
26. Please Enter Checking Account Information Here:
    "Auto-Pay" will show on your next billing in the "amount enclosed" area
28. Routing Number:*
    Enter the 9 digits that appear at the bottom left of your check (109800033 in the example)
29. Checking Account Number:*
    Enter your account number (333562222 in the example). Do not include the check number (3333 in the example).
31. Check Example
    
33. 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.
35. 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.

    1. I agree.
37. Electronic Signature*
38. Date*
    Date
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field