Automatic Withdrawal Authorization

To sign up for automatic withdrawal, please fill out the online form below or download and complete the printable form here: Automatic Withdrawal Authorization Form

Completed printable forms may be mailed or brought to City Hall along with a voided check from your financial institution. If you prefer to email your form and voided check, please send to Accounting Clerk Emily Light at elight@adeliowa.org

Automatic Withdrawal Authorization Forms must be submitted by the 15th of the month to be applied as the payment method for that month’s bill. Any forms submitted after the 15th will be applied to the following month’s bill.

Automatic Withdrawal Authorization

"*" indicates required fields

I (we) hereby authorize the CITY OF ADEL to initiate debit entries to my (our) checking account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same to such account.

Bank Name*

Bank Address*

City State Zip Code

Transit ABA Number (Routing Number)*

(Transit ABA Number is the first 9 numbers from left on bottom of your check)

Account Number*

This authority is to remain in full force and effect until the City of Adel and Depository have received written notification from me (either of us) of its termination in such time and in such manner as to afford the City of Adel and Depository a reasonable opportunity to act on it.

Name*

First Last

Second Applicant Name

(if applicable)

First Last

Service Address*

Street Address

Applicant's Signature*

The person signing this agreement is the responsible party.

Second Applicant's Signature

The person signing this agreement is the responsible party.

Copy of a VOIDED check from your financial institution*

Max. file size: 50 MB.

You will receive your water bill on the first of the month as usual. The amount due will be deducted from the above assigned account of the 20th of each month.