2. Automatic Bank Draft Authorization Form

4. Bank drafting is available to customers choosing to have their monthly utility bill deducted from their checking or savings account. To take advantage of this FREE service, simply complete and submit this authorization form, along with a voided check. 

   For more information please call (254) 799-2436.

6. 
   

   
   

   I hereby authorize the City of Bellmead to initiate debit entries to the checking or savings account indicated below. The depository financial institution named below will receive and debit same entries to my account.

   This authority is to remain in full force and effect until the Utility Collections Department has received written notification from me of its termination. Termination requests must be received 5 business days before the draft date to take effect.

   This draft may take one complete billing cycle after the completed form is returned to the City of Bellmead for the bank draft to take effect. During this time the customer is responsible for making timely payments. All bills paid by bank draft will state **Do Not Pay - Paid By Draft**.

   Automatic drafts returned by your financial institution unpaid for any reason will be charged back to your utility account and assessed a $35.00 service charge in addition to any fees your financial institution may charge. Upon return of your draft as unpaid your utility account will immediately be removed from automatic draft. 

8. Bank Name*
10. Bank Mailing Address*
12. City*
13. State*
14. Zip Code*
16. Account Type*

    1. Checking
    2. Savings
18. Customer Name*
20. Last Four of Social Security #*
21. Phone*
23. Service Address*
25. Utility Account #*
27. Signature*
28. Date*
30. Do you agree?*

    1. I agree

    By clicking "I agree" you agree and acknowledge that 1) your application will not be "signed" in the sense of a traditional paper document and 2) by signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

32. To complete this process, a voided check or bank letter must be submitted to utilitybilling@bellmeadtx.gov.  The voided check or bank letter must have the routing number and bank account number clearly visible. To determine your draft date, locate your cycle and route on your utility bill - Cycle 01, drafts the 1st of each month. Cycle 03 drafts the 15th of each month. If the draft date is on a holiday or weekend, the draft will occur the business day after. 

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field