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4. Due to the sensitivity of banking information you cannot submit this form online. You may complete and PRINT this form and hand deliver to the billing office at 101 West Gold Street Kings Mountain NC.
6. PREAUTHORIZED BILL PAYMENTS

8. Preauthorized payment is a debit application Companies with billing operations may participate in the ACH through electronic transfer (direct debit) of bill payment entries.  Through standing authorizations, the consumer grants the company authority to initiate periodic charges to his or her account(s) as bills become due

   To receive the many benefits of this service, you need to sign and authorization for us to automatically debit your personal checking or savings account.  We will transfer you debit information to the company’s bank for processing.  The information will then be transmitted to your bank or savings institution for withdrawal from your account.  Because virtually all financial institutions participate in the direct debit program, there should be no need to alter your current banking arrangement.  Consider the following benefits:

   • Convenience of not have to write checks
   • Eliminations of postage expense and the risk of late payments
   • Avoidance of late interest charges through prompt, timely payments
   • Establishment of excellent payment and credit records
10. AUTHORIZATION AGREEMENT FOR PREARRANGED PAYMENT (ACH DEBITS)

12. I (We) hereby authorize The City of Kings Mountain to initiate charges to the checking or savings account in the amount specified below, and the depository named below is authorized to debit that account.  The company will send written notice of the amount and the scheduled date of transfer at least ten calendar days before the scheduled transfer date.  

14. Name*
15. Email Address*
17. Account No - Occupant No*

    This can be found on your monthly billing statement above previous bill.  You must include your four digit account number and two digit occupant number. 

19. Bank Name*
21. Bank Routing Number*
22. Bank Account Number*

24. I authorize the City of Kings Mountain to electronically draft my account for the amount that is due on the due date. I agree to have sufficient funds available in my checking account for this service and understand that if a draft is dishonored or returned, a $25 charge will apply. Failure to comply with the terms of this contract could mean termination of this service.

    The authority is to remain in effect until the depository has received written notice of termination and has been provided a reasonable opportunity to take action. The depository customer has the right to stop the payment of debit entry by notifying the depository prior to charging the account.  If the organization initiates an incorrect debit entry to the customer account the customer shall have the right to ask the depository to credit the amount from that entry to the account.   To obtain proper credit to the account the customer shall have fulfilled the following conditions:  Notify the depository in writing of the incorrect entry within fifteen calendar days, following the date the customer received the statement of account or a written notification of that entry or 60 calendar days after posting, whichever comes first.

26. Signature*

    Typing your name here will serve as your authorized signature.

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27. Print Only

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