Riverdale City
Authorization Agreement for Utility Billing Direct Pay

Your Personal Information

Name: _________________________

Telephone Number:

Service Address: ________________________________________

Account Number: __________________(As appears on your utility bill.)

Set-up New Agreement: ____         Cancel Agreement: ____

Your Bank Information

Name of Your Bank: _____________________________________

Your Bank's Transit Number: _____________________
(NO deposit slips will be accepted)

Your Account Number: ______________________________

Type of Account: Checking _____ Savings _____

(Amount to be deducted from your account on the second to the last working day of each month)

Your Authorization

I hereby authorize Riverdale City and the financial institution designated in this application to withdraw from my account payment of my monthly utility bill.  I understand that both the financial institution and Riverdale City reserve the right to terminate this payment plan and/or my participation therein.  I also understand that at any time I may elect to discontinue my enrollment in this plan by providing written notice to Riverdale City.


  ____________________________         ____________________

             Signature                                   Date

Mail or return this form along with your voided check to:

Riverdale City

4600 S. Weber River Drive

Riverdale, Utah 84405