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I (We) hereby authorize the City of Bristol, Tennessee to initiate bank account auto pay from the financial institution and bank account indicated below.
(Please provide Street, City, State, and Zip Code.)
Please allow up to two months for your bill to automatically be withdrawn from your account. You will need to review
your bill each month and continue to pay by normal means until the notice “To Be Paid From Bank Acct” appears
on your bill. The net amount due will automatically be drafted from your account on the pay gross after date when the
message appears. Failure to pay on your account until auto pay becomes effective may subject your account to
disconnection and reconnect fees.
Any changes to banking information (new bank account, closed accounts, intent to cancel the bank account auto pay
agreement, etc.) require a one week notice for processing time in order to prevent draft related fees from being incurred.
The Finance Department will terminate this agreement if more than two transactions during a consecutive twelve month
period fail to process. A letter stating termination of the agreement will be issued to the mailing address on your account.
Payment options will be cash, money order, or credit card for one year. Eligibility for bank account auto pay can then be
resumed by completion of a new Authorization Agreement for Bank Account Auto Pay Form.
Agreement terms will remain in effect until a Cancellation Agreement for Bank Account Auto Pay Form is completed.
Please call a customer service representative at 423-989-5500 or email email@example.com with any
questions regarding your auto pay agreement.
All submissions should include a signed agreement and voided check. Submissions can be made as follows: Uploaded on this form
In person to the Finance Department (Room 203) at City Hall located at 801 Anderson Street.
Via mail to City of Bristol, Tennessee; Finance Department; PO Box 1348; Bristol, TN 37621-1348.
Via facsimile to 423-989-5719. Via email to firstname.lastname@example.org.
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