City of Mesa SurePay Authorization Agreement for Prearranged Payments (ACH debits)

Upon completion of this form, please print and send it along with a voided check to:
                 City of Mesa - Customer Service Operations
                 P.O. Box 1466
                 Mesa, AZ 85211-1466

Note: It will take about two weeks until the SurePay authorization process is completed and verified with your bank.

Customer Name:

Phone Number: --   Utility Account Number:

Name of Bank/Credit Union:

Bank/Credit Union Branch:

Bank/Credit Union Address:

Bank/Credit Union City: State:

Bank/Credit Union/ABA#: (9 digit number on bottom left of check)

Bank/Credit Union Account Number:

This authority is to remain in full force until the City of Mesa and DEPOSITORY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the City of Mesa and DEPOSITORY a reasonable opportunity to act on it. I (or either of us) has the right to stop payment of a debit entry by notification to DEPOSITORY at such time as to afford DEPOSITORY a reasonable opportunity to act on it prior to charging account. After account has been charged, I have the right to have the amount of an erroneous debit immediately credited to my account by DEPOSITORY, provided I (we) send written notice of such debit entry in error to DEPOSITORY within 15 days following the issuance of the account statement or 45 days after posting, whichever occurs first.

Signature(s): X                                                                  X

Date: