UTILITY DIRECT PAY AUTHORIZATION

ACCOUNT #: ________________________

NAME:

SERVICE ADDRESS:

CHECKING

BANK NAME

ROUTING #

ACCOUNT #

OR SAVINGS

AMOUNT / %

1.

2.

3.

I, ____________________________________, do hereby give permission for the City of Buffalo to automatically withdraw

my utility bill from my account on the 10th of every billing cycle.  I understand that this amount may not be the same everytime.

Signature

Date