Utility Bill Automatic Payment Authorization Form

Customer Name

Account Number

Service Address

Email Address

Phone Number


Name of Financial Institution

Select One:  Checking    Savings

Bank Routing Number (9 digits)

Bank Account Number


 I authorize the City of Northville and the financial institution listed above to deduct my payments for each billing period from the checking or savings account provided.  This authority will remain in effect until I notify in writing to cancel this Authorization.

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