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Automatic Draft Form

  1. Account Selection*

    I hereby authorize THE CITY OF BELMONT to initiate debit entries or such adjusting entries, either debit or credit which are necessary for corrections, to my checking or savings account indicated below and the financial institution named below to credit (or debit) the same to such account.

  2. Authorization

    I understand that this authorization will be effective until I notify my financial institution in writing that I no longer desire this service, allowing reasonable time to act on my notification. I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my account. I understand that it takes this process 60-90 days to go into effect, and until then I will need to continue to pay by bill manually (in-person, drop-off at City Hall or online). When the process is complete there will be a draft notice on my monthly billing statement. I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged. If an erroneous debit entry is charged against my account, I have the right to have the amount of the entry credited to my account by my financial institution. I agree to give my financial institution a written notice identifying the entry, stating that it is in error, and requesting credit back to my account. I will provide this written notice within 15 calendar days following the date on which I was sent a statement of my account or a written notice of such entry, or 45 days after posting, whichever occurs first.

  3. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. By signing below I have read and agree to the Parents Code of Conduct

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  5. This field is not part of the form submission.