AUTOMATIC BANK DRAFT AUTHORIZATION FORM

Please complete form in its entirety and mail to City of Southport at the address listed at the bottom of form.

***PLEASE INCLUDE A VOIDED CHECK WITH THIS FORM***

Date: ______________________________

Name:________________________________________________

Utility Account Number:__________________________

Service Address:___________________________________________________

City:__________________________State:_____________ Zip Code:______________   

Phone:________________________  Alternate Number:________________________   

Email Address:_______________________________________(Optional)

Bank Name:_________________________________________

Name(s) listed on Bank Account_______________________________________________

Bank Routing Number:___________________________

Bank Account Number:___________________________

___ Checking Account        ___ Savings Account

**By signing this form I authorize the City of Southport to draft my bank account for my monthly Utility Bill from the financial institution listed above. I have the right to stop automatic payment of my bill upon notifying the City of Southport in a timely manner.

Signature:________________________________________

City of Southport

Attn: Shaaron Aldridge/Bank Draft Program

201 E. Moore Street

Southport, NC  28461