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2. 
3. Utility Billing Department
   Authorization for Bank Draft

   Please note that bank drafts are done on the 10th of each month.
5. Utility Bill Account Number*
   Your account number can be found on bottom left of your utility bill.
6. Today's Date*
   Today's Date
8. Address*
10. City*
11. State*
12. Zip*
14. Phone Number*
16. Email Address*
    Please double check you have correctly entered your email address.
18. I HEREBY AUTHORIZE THE FINANCIAL INSTITUTION NAMED BELOW TO PAY MY MONTHLY UTILITY BILL BY CHARGING EACH PAYMENT TO MY ACCOUNT. I AGREE THAT EACH PAYMENT SHALL BE THE SAME AS IF IT WERE AN INSTRUMENT PERSONALLY SIGNED BY ME.
20. Financial Institution*
21. Bank Routing Number*
23. Savings Account Number
24. Checking Account Number
26. Draft $1 beautification donation:*
    -- Select One --YesNo
28. Upload a voided check:*
    ***A voided check or documentation with routing number and account number from the bank is required to set up a draft.***
32. I AUTHORIZE YOU TO PAY AND TO CHARGE MY CHECKING ACCOUNT THE AMOUNT OF MY MONTHLY BILL AND TO MAKE THAT DEDUCTION PAYABLE TO THE CITY OF BROWNWOOD. IN MAKING THIS AUTHORIZATION, I AGREE TO ALL THE TERMS AT THE TOP OF THIS AUTHORIZATION.
34. Signature*
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field