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2. Account Name*
4. Utility Account Number*
6. Service Address*
8. Mailing Address (if different)
10. Daytime Phone*
11. Email*
13. Account Type*

    1. Checking
    2. Savings
15. Bank Name*
17. Routing Number*
19. Bank Account Number*
21. Your Authorization*

    1. By signing this form, I certify that I am an owner of the account authorized to sign this document.

    I certify that the account numbers are accurate and authorize the City of East Lansing to deduct my payment for utilities directly from the checking or savings account indicated above on the 20th day of the month the bill is due and authorize my bank to make the payments directly to the City of East Lansing without further authorization. This authorization shall remain in effect until it is terminated by me. If I decide to terminate this payment service, I may do so at any time by notifying the City of East Lansing at least 10 days in advance of the payment due date. I further agree that if any such withdrawal and payments should be dishonored, intentionally or inadvertently, that I will be charged a $35 rejected payment fee and in no case will the City be liable for fees charged by my bank for any other resulting dishonored payments as a result of the use of this service. Further penalties may apply if the payment due is not received by the City on the due date. Please note: Forms and any change in account information must be received by the 15th of the month prior to the bill due date to be effective for the next billing cycle. The City may terminate this service at any time.
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

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