Authorization Agreement for PreAuthorized Payments

2. Information
   The City of Dyersville offers automatic bank withdrawal for payment of the water, sewer and solid waste accounts. Simply complete this form. You will receive your bill each month stating the amount that will be withdrawn from your account on the 20th. If you have any questions, please contact us. Please note the information you provide below will be emailed to the City of Dyersville. If you are not comfortable submitting you bank information online, a form in available for you to print and mail or deliver to city hall.

   The City of Dyersville offers automatic bank withdrawal for payment of the water, sewer and solid waste accounts. Simply complete this form. You will receive your bill each month stating the amount that will be withdrawn from your account on the 20th. If you have any questions, please contact us. Please note the information you provide below will be emailed to the City of Dyersville. If you are not comfortable submitting you bank information online, a form in available for you to print and mail or deliver to city hall.
4. Authorization*

   1. I hereby authorize the City of Dyersville to initiate debit entries to my account listed below.
6. Name*
7. City Account No. *
9. Depository (Bank) Name*
11. Bank Routing No.*
12. Bank Account No. *
13. Checking or Saving Account*

    1. Checking
    2. Savings
15. Your Email Address
Leave This Blank:


17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit Submit and Print

* indicates a required field