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Cancellation Agreement for Bank Account Auto Pay

  1. CITY OF BRISTOL, TENNESSEE
    FINANCE DEPARTMENT
    CANCELLATION AGREEMENT FOR BANK ACCOUNT AUTO PAY

  2. FINANCIAL INSTITUTION INFORMATION

  3. I (We) hereby authorize the City of Bristol, Tennessee to cancel bank account auto pay from the financial institution and bank account indicated below.

  4. BANK ACCOUNT AUTO PAY CANCELLATION TERMS

  5. Cancellation agreements must be received at least one week prior to the pay gross after date stated on your bill to allow time for the auto pay to be cancelled and to prevent a draft from occurring on your account. Failure to provide notice in a timely manner may result in draft related fees from being incurred and charged to your account.

    If a draft cannot be processed on your utility account due to a closure of your bank account and the Finance Department was not notified via a cancellation agreement form in a timely manner, your account may incur additional penalty and interest charges, service fees, or could be subject to disconnection of services for failure to pay.

    Please call a customer service representative at 423-989-5500 or email customerservice@bristoltn.org with any questions regarding your cancellation agreement.

  6. CUSTOMER INFORMATION

  7. Signed cancellation agreements can be submitted as follows:
    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 customerservice@bristoltn.org.

  8. FOR INTERNAL USE ONLY.

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