City of Turner Utility Customers Auto-pay Enrollment Form Complete the form below and attach a voided check (deposit slips are not acceptable due to the routing number difference) and mail it to PO Box 456, Turner, OR 97392 or drop it off at Turner City Hall. The authority you give to charge your account will remain in effect until you notify us in writing to terminate the authorization. Each month you will receive your utility bill as usual. Your bill will have a note that the amount due will be automatically withdrawn from your bank account on or about the 10th. If you wish to end your autopay, you need to notify the City by the first of the month in order to stop payment for that month. There are many advantages to this optional program. To find out more, call Tina at (503) 743-2155. AUTHORIZATION FOR DIRECT PAYMENT I authorize the City of Turner and the financial institution named below to initiate entries to my account. This authority will remain in effect until I notify you in writing to cancel it. I understand notification must occur by the first of the month in order to go in effect that month. Checking Account

Savings Account

Service Address ________________________________

City of Turner Utility Account # _________

This authority will remain in effect until I have canceled it in writing. Date FINANCIAL INSTITUTION

NAME(PLEASE PRINT)

BRANCH

ACCOUNT NUMBER AT FINANCIAL INSTITUTION

CITY

STATE

ZIP

TRANSIT ROUTING NUMBER

SIGNATURE

ACCOUNT NUMBER INFORMATION

ABA

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 STAPLE VOIDED CHECK TO THIS FORM HERE