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3. 

5. City residents with an active checking or savings account, drawn on a U.S. financial institution, are eligible for Easypay. There is no charge from the City for this service. However, additional charges may be assessed for automatic withdrawal transactions by your financial institution. Customers are responsible for inquiring with their financial institutions before enrolling in the plan. 

7. City Account Number:*
8. Name on Bank Account:*
10. Daytime Phone:*
11. Evening Phone:*
13. Account Type:

    1. Checking

    1. Savings
15. Name of Bank:*
17. ABA Routing Number:*
18. Bank Account Number:*
20. Voided Check:*

    A voided check is required to set up automatic payment

22. Terms and Conditions:

    Your monthly statement will continue to be mailed to you. “Bank Draft” will be printed in the top right corner of the statement, and where the total due amount is shown it will say “Bank account drafted for” indicating that this amount will be deducted from you bank account on the DUE DATE.

    Until this information prints on your bill, continue to remit payments. If your payment is not honored by your financial institution for any reason, it will be treated similar to a returned check. An NSF fee will be assessed per Florida Statute 68.065(2) and will be added to you account for each occurrence of a non-paid debit. Additionally, there will be a reconnection charge should utility services be interrupted due to nonpayment. The City reserves the right to remove any account from the plan which has incurred three insufficient nonpaid withdrawals. 

    Payments will be drawn upon the bank account authorized at the time of billing.

    If you discontinue service, it will be necessary for you to pay your last statement with cash, check or money order. Your final bill cannot be paid through Easypay.

24. Acknowledgement:

    1. I have read and understand the terms and conditions, and hereby authorize my financial institution to debit my account in the name of the City of Altamonte Springs.
26. Signature:*
27. Date:*
    Date:
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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