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CITY OF LITTLE CANADA <br />AUTOMATIC UTILITY BILL PAYMENT PROGRAM <br />This auto -pay program is optional. When you enroll in the City of Little <br />Canada's automatic payment program, you will still receive a utility <br />invoice; however, no action will be required on your part. <br />Your payment for the full balance due on your account will be deducted <br />from your checking or savings account approximately one week before <br />the due date. If you have any questions about the automatic payment <br />program, please call the city's accounting technician at 6651 - 7664034. <br />Please staple a voided check or savings deposit slip to this form and mail entire <br />page to: UB ACH, City of Little Canada, 515 Little Canada Road, Little Canada, MN. <br />55117 <br />Authorization Agreement for Automatic Payment Program <br />UWe authorize the City of Little Canada through it's bank to initiate debit entries to my /our account <br />indicated below, and the financial institution named below to debit the same such account. This <br />authority is to remain in full force and effect until the City of Little Canada has received notification <br />from me /us of the termination in such time and in such manner as to afford the financial institutions <br />and the City of Little Canada a reasonable opportunity to act upon the termination. <br />I/We authorize the City of Little Canada to initiate entries to debit my /our account below: <br />(please select and list either your checking or saving account) <br />Checking Account # Savings Account # <br />Checking Account Routing # (lower left of check) <br />Financial Institution Name and Phone Number <br />City of Little Canada Utility Account Number <br />Service Address for this Account <br />Name listed for this Account <br />By signing this authorization form, Uwe acknowledge that I /we understand that the dollar amount due <br />each quarter will vary according to usage and yearly rate. <br />Signed by: Date: <br />Signed by: Date: <br />