Automatic Bank Draft Authorization

If you wish to have your bill payment automatically drafted from your checking/savings account,
please fill out the following information and return to our office at 205 W 3rd Pl, Russellville, Ar. or
Mail to:  City Corporation, PO Box 3186, Russellville Arkansas 72801-3186. Fax to 479-968-3265.

City Corporation Customer Account number:___________________________________

Your Name (As shown on the above account):_________________________________

Address:_______________________________________________________________

City:__________________________

State:________________________

Zip Code:_____________________

Phone:_______________________

Financial Institution:_____________________________________________________

City:______________________________

State:_____________________________

Check One:  Checking Account_______  Savings Account________

Account Number:______________________________________________________

IMPORTANT:  Please return a voided check with this form to ensure accurate processing.

I authorize City Corporation To charge my checking/savings account the amount of my monthly water bill and to make that deduction payable to City Corporation. I agree to all the Terms and Conditions of authorization.

Date:__________________

Signature:__________________________________