Automatic Draft Authorization

ACH Debit Authorization Agreement Application

"*" indicates required fields

I (we) hereby authorize the City of Ball Ground (CBG) to Debit my banking account at the financial institution listed below for payment on my monthly bill. This authorization will remain in effect until I (we) notify CBG in writing that I (we) no longer desire this service, allowing CBG and the financial institution reasonable time to act on my (our) notification.

Account Name (s)*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Enter Email Confirm Email

Phone*

CBG Account Number*

Alternate Phone

Name of Financial Institution*

Phone Number for Financial Institution*

Type of Account*

Checking

Savings

Commercial

Personal

Upload image of a voided check, NOT a deposit slip*

Accepted file types: jpg, gif, png, pdf, webp, Max. file size: 32 MB.

Upload image of your driver's license*

Accepted file types: jpg, gif, png, pdf, webp, Max. file size: 32 MB.

Once you are enrolled, you will continue to receive your monthly bill. "Drafted on (date): Don't Pay" will print on your bill as a reminder that the account is being drafted. The amount due on your bill is automatically deducted from your checking account 2-4 business days prior to the due date.

Name

This field is for validation purposes and should be left unchanged.

Automatic Draft Authorization

ACH Debit Authorization Agreement Application

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