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Automatic Draft Form

  1. Automatic Draft Form
  2. Account Selection*
  3. I hereby authorize THE CITY OF LOWELL to initiate debit entries or such adjusting entries, either debit or credit which are necessary for corrections, to my checking or savings account indicated below and the financial institution named below to credit (or debit) the same to such account.
  4. AUTHORIZATION: I understand that this authorization will be effective until I complete and turn in a Voluntary Termination ACH draft form at City Hall stating that I no longer desire this service, also allowing reasonable time for the City of Lowell to act on my notification. I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my utility account only. No checks are issued at the counter at City Hall. My drafts will not end until my final bill has been processed if I am closing out my current water account with the City of Lowell. I understand my draft amount is controlled by the consumption or amount of water I use monthly. The draft amount will not necessarily be the same each month due to either more water used or a potential rate increase. Also, if a leak goes unnoticed by me and the City of Lowell prior to the draft, I understand that the City of Lowell is not responsible for an overdraft on my account or penalties incurred by my financial institution. During the next month's billing cycle any potential credit will be placed back on my account after I have met all leak adjustment requirements. I understand if my draft utility payment is declined due to insufficient funds in my account, I will be charged a late fee and will be responsible for the full amount of my utility bill plus the late fee within five days in order to not have my service interrupted during the cut-off period on the 25th of the month. If my service is interrupted during the cut-off period I will also be charged a $50 delinquent fee.
  5. 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.
  6. Agreement:*
  7. Leave This Blank:

  8. This field is not part of the form submission.