E-Gov Services Pikeville City

BankDraft Form

City Of Pikeville

118 College St

Pikeville, Ky 41501

Telephone: (606) 437-5124

Fax: (606) 437-5106

AUTHORIZATION FOR AUTOMATIC FUNDS TRANSFER

The undersigned authorizes The City of Pikeville to charge the undersigned checking or savings account for their monthly utility bill.

It is futher agreed that the designated account will be maintained with a sufficient balance to cover the monthly payments. The City of Pikeville will Charge a fee for transfers that cannot be completed due to insufficient funds according to the same guidelines as a retuned check.

The authorization by the customer and its acceptance by The City of Pikeville may be terminated with a thirty day written notice.

* Information is required.

Contact Information

* First Name:

* Last Name:

* Business Name:

Email:

* Daytime Phone: () –

Fax: () –

* Address:

* City:

* State:

* ZIP:

* Customer Number:

* Check Account Number

* Check Routing Number

* Name of Bank:

* Bank Address:

* City:

* State:

* Zip Code:

Service Address if different from above:

Check here to have email confirmation of this request sent.

* Information is required.

Notes:
Please send a copy of a voided check with this form. You may mail a copy, fax a copy, or email a copy of the voided check.

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