2. 

3. 
   

   BANK DRAFTING

   AUTOMATIC WITHDRAWAL AUTHORIZATION

   
   

4. City of Tarpon Springs

   Utility Billing Division
   PO Box 5004
   Tarpon Springs, FL 34688-5004
   Phone: (727) 942-5609  Email: ubcts@ctsfl.us

8. * ACCOUNT BALANCE MUST BE AT A ZERO BALANCE BEFORE THE AUTO DRAFT CAN BE SET UP*

10. Customer Information

12. Customer Name(s)
13. First Name*
14. Last Name*
17. First Name
18. Last Name
20. Street (Service) Address*
22. City*
23. State*
24. Zip Code*
26. Cell Phone*
27. Home/Work Phone
29. City of Tarpon Springs Account #*

31. 
    

    Financial Information

33. Name*
34. Branch*

36. Bank, credit union or other financial institution located in the U.S. that participates in automatic withdrawal.

38. Address*
40. City*
41. State*
42. Zip Code*
44. Bank Account #*
45. Bank Account Routing #*
47. Upload Image*

    Attach image of a voided blank check for account number verification.

49. Bank Drafting will begin with your next cycle bill after we receive your authorization form or next cycle bill once you sign up online. 

    Online customers please note existing  charges will not draft.

51. *Draft date will be 12 days after bill date*

53. I/We authorize the City of Tarpon Springs to initiate monthly debits to my/our bank account at the financial institution named above.

55. Electronic Signature*
56. Date Signed*
    Date Signed
58. Electronic Signature
59. Date Signed
    Date Signed
61. 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.
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field